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Milk Donation
Milk Donation
f2b_admin
2019-06-05T05:29:09-05:00
If you are human, leave this field blank.
Donor Criteria Form
Name
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Email
*
Phone Number
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Best way to be contact
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Email
Number
1. Are you taking any medication, prescription or over-the-counter
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Yes
No
If Yes Please List
2. Do you consume alcohol?
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Yes
No
If yes, please describe your present daily intake.
3. Please describe your daily or weekly intake of caffeine.
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4. Have you had any breast infections with this baby?
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Yes
No
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.)
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Yes
No
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)?
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Yes
No
7. Have you had exposure to someone with HIV or AIDS in the last 12 months?
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Yes
No
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
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Yes
No
9. Have you had an accidental needle stick, or exposure to someone else’s blood?
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Yes
No
10. Have you ever had tuberculosis, exposure to TB, or a positive TB test or chest X-ray?
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Yes
No
11. Have you or anyone in your household been coughing up blood and running a fever?
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Yes
No
12. In the last 12 months have you tested positive for or been treated for syphilis, gonorrhea, or chlamydia?
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Yes
No
13. Have you had a skin disease or unexplained skin lesions?
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Yes
No
14. In the last 12 months have you had any vaccinations or shots?
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Yes
No
15. Did you have any illness or complication due to the vaccination?
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Yes
No
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?
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Yes
No
17. If you had the smallpox vaccination, has the vaccination scab fallen off your skin by itself?
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Yes
No
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?
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Yes
No
19. Do you have or have you had yeast infections (oral, vaginal or systemic) or unexplained white sores or lesions in the mouth?
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Yes
No
20. Do you have or have you had unexplained weight loss, persistent diarrhea, fever, or night sweats?
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Yes
No
21. Do you have or have you had unexplained enlarged lymph nodes?
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Yes
No
22. In the last 12 months have you received blood, blood products, or an organ or tissue transplant?
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Yes
No
23. Do you have a history of cancer?
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Yes
No
If yes, when and what kind?
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24. Are you currently expecting?
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Yes
No
25. Is your baby deceased?
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Yes
No
Please Confirm
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