2. What is your date of birth?

Have you ever donated blood?

Yes No

Have you donated in the last three years?

Yes No

Have you donated in the last year (364 days)?

Yes No

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)?

Yes No

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

Yes No

5.1. Have you travelled outside of Europe?

Yes No

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

Yes No

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

Yes No

8. Are you taking medication?

Yes No

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

Yes No

Hepatitis B

Whooping cough

Influenza (flu)

Yellow fever

Tetanus

SARS-CoV-2 (COVID 19)

Other

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

Yes No

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

Yes No

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

Yes No

13. Have you already used drugs?

Yes No

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

Yes No

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

Yes No

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

Yes No

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.

1. Are you male or female?

2. What is your date of birth?

Have you ever donated blood?

Have you donated in the last three years?

Have you donated in the last year (364 days)?

3. What is your weight and your height?

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?

Tick the medicines you are taking in the list below

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!

Blood donation registration