Milk Donation

Donor Criteria Form

Name *

Email *

Phone Number *

Best way to be contact *

Number

1. Are you taking any medication, prescription or over-the-counter *

Yes

If Yes Please List

2. Do you consume alcohol? *

Yes

If yes, please describe your present daily intake.

3. Please describe your daily or weekly intake of caffeine. *

4. Have you had any breast infections with this baby? *

Yes

If yes, please give dates and describe what treatment was needed

5. Are you on any special diet? (e.g. vegetarian, low salt, low calorie, diabetic, dairy-free, etc.) *

Yes

If so, please explain.

6. In the last 12 months have you had close contact with a person with jaundice or viral hepatitis or have you been given Hepatitis B Immune Globulin (HBIG)? *

Yes

7. Have you had exposure to someone with HIV or AIDS in the last 12 months? *

Yes

8. In the last 12 months have you or your sexual partner had ears or body parts pierced with other than single-use instruments, a tattoo with non-sterile needles or multiperson dyes from a non-regulated site, permanent make-up applied with needles, or *

Yes

9. Have you had an accidental needle stick, or exposure to someone else’s blood? *

Yes

10. Have you ever had tuberculosis, exposure to TB, or a positive TB test or chest X-ray? *

Yes

11. Have you or anyone in your household been coughing up blood and running a fever? *

Yes

12. In the last 12 months have you tested positive for or been treated for syphilis, gonorrhea, or chlamydia? *

Yes

13. Have you had a skin disease or unexplained skin lesions? *

Yes

14. In the last 12 months have you had any vaccinations or shots? *

Yes

15. Did you have any illness or complication due to the vaccination? *

Yes

If Yes, Please explain

16. In the past 8 weeks have you received smallpox vaccination, or have you had close contact with the vaccination site of anyone else? *

Yes

17. If you had the smallpox vaccination, has the vaccination scab fallen off your skin by itself? *

Yes

18. If you have had close contact with the vaccination site of anyone else, have you had any new skin rash or sore since the time of that contact? *

Yes

19. Do you have or have you had yeast infections (oral, vaginal or systemic) or unexplained white sores or lesions in the mouth? *

Yes

20. Do you have or have you had unexplained weight loss, persistent diarrhea, fever, or night sweats? *

Yes

21. Do you have or have you had unexplained enlarged lymph nodes? *

Yes

22. In the last 12 months have you received blood, blood products, or an organ or tissue transplant? *

Yes

23. Do you have a history of cancer? *

Yes

If yes, when and what kind? *

24. Are you currently expecting? *

Yes

25. Is your baby deceased? *

Yes

Please Confirm *

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