| 1 | Are you in 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 medications during the past month? | | |
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| 6 | Have you had a vaccination recently? | | |
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| 7 | Are you currently under medical supervision? | | |
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| 8 | Have you travelled abroad in the last 6 months? | | |
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| 9 | Have you undergone any medical procedures involving medical instruments in the past 6 months? | | |
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| 10 | Have you had your earlobes pierced, received a tattoo, or undergone acupuncture within the last 6 months? | | |
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| 11 | Have you received a blood transfusion or transfusion of blood components within the last 6 months? | | |
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| 12 | Within the last 6 months, have you had close contact with anyone diagnosed with an infectious disease (including sharing a household or engaging in sexual activity), specifically Hepatitis B, Hepatitis C, HIV/AIDS, or syphilis? | | |
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| 13 | Have you ever been diagnosed with, or do you currently have, any of the following conditions? 1. Diseases that may pose a risk to others (e.g., HIV/AIDS, Hepatitis B, Hepatitis C, tuberculosis, brucellosis, etc.) 2. Sexually transmitted infections (STIs) (e.g., syphilis, etc.) 3. Cardiovascular diseases (e.g., hypertension/high blood pressure, myocardial infarction/heart attack, stroke, etc.) 4. Chronic respiratory diseases (e.g., bronchial asthma, chronic obstructive pulmonary disease (COPD), emphysema, etc.) 5. Malignant neoplasms (cancers) or blood disorders 6. Diabetes mellitus or gastrointestinal ulcers 7. Any other chronic medical condition | | |
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| 14 | Have you recently experienced, or have you ever experienced, unexplained weight loss, night sweats, or fainting (loss of consciousness)? | | |
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| 15 | Have you ever donated blood or blood components? | | |
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| 16 | Has a blood collection organization ever refused to accept your blood donation? If yes, please provide the reason and the date. | | |
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| 17 | Within the past 6 months, have you had sexual contact with a casual or non-regular partner? | | |
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| 18 | Are you currently donating blood in exchange for financial compensation? | | |
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| 19 | Please indicate: 1) If you are currently pregnant 2)If you are currently breastfeeding 3)The date of your last menstrual period inform the doctor | | |
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| 20 | Have you had a childbirth or a termination of pregnancy (induced abortion) within the past year? | | |
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| 21 | Additional questions (for healthcare workers) Within the past 6 months, have you had an occupational exposure incident involving contact between a patient’s biological fluids and your eyes, nose, mouth, mucous membranes, or broken skin? | | |
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| 22 | Providing false or incomplete information about your health condition may endanger your health during blood donation. Articles 177, 178, 179, 180, and 181 of the Criminal Code of the Republic of Armenia provide for criminal liability for concealing, providing incorrect, or distorting information that results in infecting another person with HIV, sexually transmitted infections, or other diseases dangerous to public health (such as brucellosis, tuberculosis, viral hepatitis, etc.). | | |
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| 23 | Signature | | |
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