Blood Donation Form

Collect the medical history and contact details a clinic or blood bank needs to screen a donor's eligibility before a blood drive.

Use this template

Already have an account? Log in

What is your blood type?

A+ A- B+ B- O+ O- AB+ AB-

Full Name

Nombre

Apellido

Birth Date

Gender

Male Female Other Prefer not to say

Occupation

Phone Number

Address

Dirección

Ciudad

Estado / Provincia

Código postal

Weight

Pulse

Hemoglobin (Hb)

Blood Pressure (BP)

Temperature

What was the last time you donated blood?

Have you donated previously?

Yes No

In the last six months, have you had any of the following?

Fever New tattoo or piercing Surgery Vaccination Travel abroad Dental treatment

Do you suffer from, or have you suffered from, any of the following diseases?

Diabetes Hepatitis HIV/AIDS Heart disease Cancer Tuberculosis

Are you taking, or have you taken, any of these in the past 72 hours?

Aspirin Antibiotics Blood thinners Alcohol

Is there any history of surgery or blood transfusion in the past six months?

Surgery Blood transfusion None

Related templates

3 Day Diet Diary Form Healthcare Abortion Opinion Survey Healthcare Academic Planning Form Education Academic Research Survey on Sexual Health Healthcare

Powerful online forms — builder, logic, products, and teams — at a price that makes sense.

Rejoining the server...

Rejoin failed... trying again in seconds.

Failed to rejoin.
Please retry or reload the page.

The session has been paused by the server.

Failed to resume the session.
Please retry or reload the page.