| DONOR HISTORY |
Are you feeling well today ?
Had malaria within the last three years?
Had heart disease, chest pain or shortness of breath ?
Had convulsions, seizures, or fainting spells ?
Had a blood disease or abnormal bleeding ?
Been pregnant in past 6 weeks ?
Night sweats, Enlarged lymph nodes, Unexplained weight loss ?
Unexplained fever, Purple skin lesions, Persistent cough ?
White spots or unusual blemishes in mouth ?
Consent to having HTLV-III antibody testing done?
Had any dental work in past 3 days ?
Been hospitalized in past 6 months ?
Had blood transfusions, injections, or tattoos in past 6 months ?
Had any vaccinations/immunizations in past year ?
Traveled outside US in past 3 years ?
Ever had jaundice, liver disease, or hepatitis ?
Been deferred as a blood donor or had problems donating ?
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