Blood Donation Form Confidential – Please answer the following questions correctly. This will help to protect you and the patient who receives your blood. What is your blood type?0 Rh +0 Rh -A Rh +A Rh -B Rh +B Rh -AB Rh +AB Rh -NameBirth DateDaySelect day12345678910111213141516171819202122232425262728293031MonthSelect month123456789101112YearSelect Year212521242123212221212120211921182117211621152114211321122111211021092108210721062105210421032102210121002099209820972096209520942093209220912090208920882087208620852084208320822081208020792078207720762075207420732072207120702069206820672066206520642063206220612060205920582057205620552054205320522051205020492048204720462045204420432042204120402039203820372036203520342033203220312030202920282027202620252024202320222021202020192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925GenderMaleFemaleOccupationPhoneEmail AddressStreet AddressCityState/ProvinceZIP / Postal CodeWeightWeight PulseHbBPTemparatureWhat was the last time you donated blood?Have you donated previously?YesNoIn the last six months have you had any of the following?TattooingEar piercingDental extractionDo you suffer from or have suffered from any of the following diseases?Heart DiseaseDiabetesSexually Transmitted DiseasesLung DiseaseAllergic DiseaseEpilepsy (Charay rogJaundice (last one year).Fainting spells.Cancer/Malignant DiseaseHepatitis B/CTyphoid (last on year) (Antay joro)TuberculosisKidney Diseaseabnormal Bleeding tendency.Malaria (six months)Are you taking or have you taken any of these in the past 72 hours?AntibioticsAspirinAlcoholSteroidsVaccinationsDog bite Rabies vaccine (1 year)Is there any history of surgery or blood transfusion in the past six months?MajorMinorBlood TransfusionSend Message