Blood Donation Screening Form

Blood Donation Screening Form — Form Fields

This healthcare template includes 6 fields. Pre-screen prospective blood donors for eligibility based on health history, recent travel, and lifestyle factors. Ensures donor safety and blood supply quality. Streamlines the donor check-in process at blood drives. Free to customize and use on ZenBuild.

• Donor Full Name (text, required)
• Date of Birth (text, required)
• Do you feel well today and are you in good health? (multiple choice, required) — options: Yes, No – I have symptoms
• Have you donated blood in the past 56 days (8 weeks)? (multiple choice, required) — options: No, Yes
• Have you traveled outside the country in the past 3 months? (multiple choice, required) — options: No, Yes – please discuss with staff
• Blood Type (if known) (dropdown selection, optional) — options: A+, A-, B+, B-, AB+, AB-, O+, O-, Unknown