What is your blood type?
O Rh+
A Rh+
B Rh+
AB Rh+
O Rh-
A Rh-
B Rh-
AB Rh-
Full Name
Birth Date
Male
Female
Address
Yes
No
In the last six months have you had any of the following?
Tattooing
Ear piercing
Dental extraction
Do you suffer from or have suffered from any of the following diseases?
Heart Disease
Diabetes
Sexually Transmitted Diseases
Lung Disease
Allergic Disease
Epilepsy (Charay rog)
Jaundice (last one year)
Fainting spells
Cancer/Malignant Disease
Hepatitis B/C
Typhoid (last one year)
Tuberculosis
Kidney Disease
Abnormal Bleeding Tendency
Malaria (six months)
Are you taking or have you taken any of these in the past 72 hours?
Antibiotics
Aspirin
Alcohol
Steroids
Vaccinations
Dog bite Rabies vaccine (1 year)
Is there any history of surgery or blood transfusion in the past six months?
Major
Minor
Blood Transfusion