{"aaData": [["ALCOHOL", "
\nAre you feeling well today ?\nHad malaria within the last three years?\nHad heart disease, chest pain or shortness of breath ?\nHad convulsions, seizures, or fainting spells ?\nHad a blood disease or abnormal bleeding ?\nBeen pregnant in past 6 weeks ?\nNight sweats, Enlarged lymph nodes, Unexplained weight loss ?\nUnexplained fever, Purple skin lesions, Persistent cough ?\nWhite spots or unusual blemishes in mouth ?\nConsent to having HTLV-III antibody testing done?\nHad any dental work in past 3 days ?\nBeen hospitalized in past 6 months ?\nHad blood transfusions, injections, or tattoos in past 6 months ?\nHad any vaccinations/immunizations in past year ?\nTraveled outside US in past 3 years ?\nEver had jaundice, liver disease, or hepatitis ?\nBeen deferred as a blood donor or had problems donating ?\n\n
\nThe medical history which I have furnished is true and accurate, to the best\nof my knowledge. I consent to having the HTLV-III antibody testing\nperformed and understand that I will be informed of the test results,\nshould the test be positive, no sooner than 55 days from today.\nI hereby grant permission to the Veterans Administration\nBlood Bank to draw approximately 450 ml. of blood from me, to be used in\nsuch a manner as the Blood Bank may deem desirable.\n\n