1. Are you male or female?

2. What is your date of birth?

Have you donated blood over the last three years?

3. What is your weight and your height?

Kg Cm

4. Did you live in the United Kingdom (England, Scotland, Wales and Northern Ireland) from 1980 to 1986 for longer than 6 months (all times spent living there during this time span combined)?

5. Have you travelled outside of Belgium over the last 6 months?

5.1. Have you travelled outside of Europe?

6. Are you pregnant or have you given birth over the last 6 months (including miscarriage or termination of pregnancy)?

7. Did you recently run a fever or contract an infection (bronchitis, urinary infection, etc.)?

8. Are you taking medication?

9. Have you been vaccinated less than a month ago?

10. Have you undergone an endoscopy (arthroscopy, gastroscopy, colonoscopy, etc.) or an operation over the last 4 months?

11. Did you see the dentist over the last 7 days?

12. Have you had a piercing (including ear rings), a tattoo (including permanent make-up) applied over the last 4 months?

13. Have you already used drugs?

14. Have you had a new sex partner over the last 4 months? (with or without protection)

15. Have you had a new sex partner over the last 4 months? (with or without protection)

16. Have you had a sexual relationship with a male over the last 4 months?

End. Thank you for taking the test!

Based on your replies  - unless you have continued with the test despite being notified of a contraindication - you are allowed to donate blood. However, this online questionnaire is for general guidance only. At the time of the collection, you will be asked to complete a medical questionnaire and undergo a medical examination ahead of the donation. Only the doctor is qualified to confirm whether or not you are suitable to donate blood.

 

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1. Êtes-vous un homme ou une femme ?

2. Quelle est votre date de naissance ?

Avez-vous fait un don ces trois dernières années ?

3. Quel est votre poids et votre taille ?

Kg Cm

4. De 1980 à 1996, avez-vous séjourné plus de 6 mois (tous séjours confondus) au Royaume-Uni (Angleterre, Écosse, Pays de Galles et Irlande du Nord) ?

5. Avez-vous voyagé hors de la Belgique ces 6 derniers mois ?

5.1. Avez-vous voyagé à l’extérieur de l’Europe ?

6. Êtes-vous enceinte ou avez-vous accouché dans les 6 derniers mois (y compris fausse couche ou interruption de grossesse) ?

7. Avez-vous eu récemment de la fièvre ou une infection (bronchite, infection urinaire...) ?

8. Prenez-vous des médicaments ?

9. Avez-vous été vacciné.e il y a moins d’un mois ?

10. Avez-vous subi une endoscopie (arthroscopie, gastroscopie, coloscopie…) ou une opération dans les 4 derniers mois ?

11. Êtes-vous allé.e chez le dentiste au cours des 7 derniers jours ?

12. Avez-vous fait un piercing (y compris boucles d’oreilles) ou un tatouage (y compris maquillage permanent) durant ces 4 derniers mois ?

13. Avez-vous déjà consommé de la drogue ?

14. Avez-vous eu un.e nouveau.elle partenaire sexuel.le au cours des 4 derniers mois ? (avec ou sans préservatif)

15. Avez-vous eu une nouvelle partenaire sexuelle au cours des 4 derniers mois ? (avec ou sans préservatif)

16. Au cours des 4 derniers mois, avez-vous eu une relation sexuelle avec un homme ?

End. Merci d’avoir fait le test !

Based on your replies - unless you have continued with the test despite being notified of a contraindication - you are allowed to donate plasma. However, this online questionnaire is for general guidance only. At the time of the collection, you will be asked to complete a medical questionnaire and undergo a medical examination ahead of the donation. Only the doctor is qualified to confirm whether or not you are suitable to donate blood.

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