Donate BLOOD...Donate life
Answers marked with a * are required.
Blood Donation Questionnaire
1.
Gender
*
Male
Female
2.
Have you ever donated blood?
*
Yes
No
If YES answer questions 3 – 6
If NO answer questions 7- 15
3.
Do you donate
regularly
occasionally
sporadically
4.
Were you investigated for the following before donating?
HB level
Weight
Blood pressure
Temperature
Pulse
5.
Were you informed by the safety instructions that should be followed after donation as
Drinking liquids especially first 4 hrs after donation
Do not smoke
Do not get exposed to sun
Do not exert physical effort
6.
Do you receive calls for donation from where you have donated before?
Yes
No
7.
Why haven't you ever donated blood?
You suffer from Anemia or you are underweight
Afraid of needles
Afraid of getting infected by a disease
Afraid of complications as fatigue
You have never been asked (you did not have the chance)
Other (Please Specify)
8.
Do you know anyone who had ever donated blood and had any short/long term complications? if yes, please mention the complication/s
9.
Is there a blood donation centre near your residence/place of work?
Yes
No
I have never been concerned
10.
If you would donate blood what would be the reason?
Save someone's life
Would help avoid blood shortages
Would be a gesture of generosity towards people in need.
Other (Please Specify)
11.
If you were to donate blood your family members would you
Strongly Disapprove
Neither Disapprove nor approve
Strongly Approve
12.
How many people you know donate blood?
Many
Few
Not at all
13.
If you were informed that blood supplies of the same blood group as yours were low you would immediately donate blood
Yes
No
May be
14.
If you were accompanied by a friend or family member you would be encouraged to donate blood than if you were alone
Yes
No
It would make no difference
15.
Do you believe that blood donation is dangerous on your health? if yes, Please mention Why?
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