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Whether you’re having trouble with your account, or would like to make a suggestion, Canadian Blood Services offers you quick and convenient options to troubleshoot or get in touch. Contact us via live chat, consult our FAQ, send an email feedback@blood.ca, or give us a call at 1 888 2 DONATE (1-888-236-6283).

Donor Questionnaire

What is the Donor Questionnaire?

The Donor Questionnaire captures all the relevant information about you and your donation. It is a confidential questionnaire that helps decide if you are eligible to give blood.

Wellness today

The following questions ask about your wellness today.

1

Are you feeling well today?

2

Do you have a:

flu

sore throat

fever

infection?

Drugs, vaccines

The following questions ask about medications and shots you may have taken.

3

In the last 3 days have you taken medication (including Aspirin), other than birth control pills or vitamins?

4

In the last month have you taken any of the following medications:

Accutane, Epuris, Clarus, Isotretinoin

Toctino, Alitretinoin

Proscar, Propecia, Finasteride?

5

In the last 3 months have you had a vaccination?

6

In the last 6 months have you taken any of the following medications:

Avodart, Jalyn, Dutasteride?

7

In the last 12 months have you had a rabies shot?

8

Have you ever taken any of the following medications:

Tegison

Soriatane

Human pituitary growth hormone?

General Medical

The following questions are about your medical history.

9

Do you have diabetes?

10

In the last 3 days have you had dental work?

11

In the last 6 months have you consulted a doctor for a health problem, had surgery or medical treatment?

12

In the last 6 months have you been pregnant? (female)

13

In the last 12 months have you had a graft?

14

In the last 12 months have you had close contact with a person who has had hepatitis or yellow jaundice?

15

In the last 12 months have you received blood or blood products?

16

Since 1980, did you receive a blood transfusion or blood product in the United Kingdom, France or elsewhere in Europe?

17

Have you ever taken clotting factor concentrates?

18

Have you ever had malaria?

19

Have you ever had yellow jaundice (other than at birth) or hepatitis?

20

Have you ever been pregnant, miscarried or had an abortion? (female, apheresis all types)

21

In the last month have you had an AIDS (HIV) test other than for donating blood?

22

Do you have AIDS or have you ever tested positive for HIV/AIDS?

23

Have you ever had epilepsy or fainting?

24

Have you ever had a coma or stroke?

25

Have you ever had problems with your heart or lungs?

26

Have you ever had kidney or blood problems?

27

Have you ever had cancer?

28

Have you ever had Crohn’s disease?

29

Have you ever received a dura mater (brain covering) graft?

30

Have you ever had Chagas' disease, Babesiosis or Leishmaniasis?

31

Do you have a biological (blood relative) parent, child or sibling diagnosed with Creutzfeldt-Jakob Disease (CJD)?

Travel

The following questions are about your travel history.

32

In the last 12 months have you travelled outside Canada and the U.S. and stayed less than 6 months?

33

In the last 8 weeks have you travelled outside Canada?

34

In the last three and a half years have you spent more than 6 months in a continuous period outside Canada or the U.S.?

35

From January 1, 1980 through December 31, 1996 have you spent a total of 3 months or more in the United Kingdom (England, Northern Ireland, Scotland, Wales, the Isle of Man, or the Channel Islands)?

36

Have you spent a total of 3 months or more in France from January 1, 1980 through December 31, 1996?

37

Have you spent a total of 5 years or more in Europe from January 1, 1980 through December 31, 2007?

38

Have you spent a total of 6 months or more in Saudi Arabia from January 1, 1980 through December 31, 1996?

39

In the last 12 months have you been in Togo or Cameroon?

40

Have you spent a total of 6 months or more in a continuous period in Mexico, Central America or South America?

41

Were you born in Mexico, Central America or South America?

42

Was your mother or maternal grandmother born in Mexico, Central America or South America?

Lifestyle

The following questions are lifestyle related questions.

43

In the last 6 months have you had a tattoo?

44

In the last 6 months have you had skin or ear piercing?

45

In the last 6 months have you had acupuncture?

46

In the last 6 months have you had electrolysis?

47

In the last 6 months have you had an injury from a needle or come in contact with someone else's blood?

48

In the last 6 months have you had sex with anyone who has taken clotting factor concentrates?

49

In the last 12 months have you taken illegal steroids with a needle?

50

In the last 12 months have you had or been treated for syphilis or gonorrhea?

51

In the last 12 months have you been in jail or prison?

52

In the last 12 months have you used cocaine?

53

In the last 12 months have you had sex with a sex trade worker or anyone else who has taken money or drugs for sex?

54

In the last 12 months have you had sex with anyone who has ever taken illegal drugs with a needle?

55

In the last 12 months have you had sex with a man who, in the last 12 months, had sex with another man? (Female)

56

In the last 12 months, have you had sex with another man? (Male)

57

At any time since 1977 have you taken money or drugs for sex?

58

Have you ever taken illegal drugs with a needle even one time?

59

Have you had sex with anyone who has AIDS or has tested positive for HIV or AIDS?

60

Have you had sexual contact with anyone who was born or lived in Togo or Cameroon since 1977?

61

Have you, in your past or present job, taken care of or handled monkeys or their body fluids?

62

Did you make your last donation or last attempted donation at Héma-Québec?