| 1 | Are you in a good health? | | |
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| 2 | Do you have any complaints about your health? | | |
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| 3 | Have you had a meal or snack in the last 4 hours? | | |
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| 4 | Have you used alcohol during the past 24 hours? | | |
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| 5 | Have you taken any medication during the past month? | | |
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| 6 | Have you had a vacctination recently? | | |
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| 7 | Are you currently under the medical surpervision? | | |
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| 8 | Have you travelled abroad in the last 6 months? | | |
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| 9 | Have you had medical investigation, body piercing, tattoo, acupuncture treaatment, accidental injury involving a needle, and/or muscous membrane exposure to bloddd in the last 6 month? | | |
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| 10 | Have you received blood or blood products in the last 6 months? | | |
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| 11 | Have you had any contact with a patient suffering from an infectious disease? | | |
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| 12 | Have you had fainting, weight loss more than 5 kg, drenching night sweat? | | |
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| 13 | Have you ever had a serious illness? If yes, mention please. Have you ever undergone surgery? | | |
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| 14 | Have you ever donated blood or blood components? If yesthen when? | | |
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| 15 | Have you ever had contraindication for blood components? If yes then when? | | |
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| 16 | Have you had sex with non-permanent partner in the last 6 month? | | |
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| 17 | Are you non-remunerated blood donor? (appendix 18.10.18 N23-N) | | |
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| 18 | For Women / Are you pregnant or breastfeeding now? | | |
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| 19 | Have you had miscarriage or an abortion in the last 1 year? | | |
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| 20 | I am informed that providing incomplete or wrong information about my health my harm it during donation. Providing incomplete or wrong information about my sexual behavior (high-risk sexual behavior include having multiple sex partners, receiving or paying money or drugs for sex, including sex workers and their clients, men having sex with men (MSM) and females having sex with MSM) may harm a recipient's health and by the RA Law I am responsible for spreading transfusion transmissible infections (123, 124 articles). I am also informed that I have a right to refuse blood donation, as well as to declare the blood or blood components useless after the donation, without any explanation. I am informed that the positive results of my blood tests (hepatits, HIV) will be sent to the appropriate medical estabilishment. I agree to donate blood or blood components.) | | |
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| 21 | Signature | | |
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