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Additional Information
Are you using birth control?
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Do you smoke?
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Do you have children?
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What method of birth control do you use?
Have you been a donor before?
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How many children do you have?
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Required Questions
FDA regulations require that we ask you the following questions. Your complete honesty and accuracy are essential and appreciated. A "Yes" answer to any of the following questions will not necessarily disqualify you.
In the past 12 months, have you had a blood transfusion?
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Yes
No
Have you ever had a blood transfusion in England, Wales, Scotland, Northern Ireland, Channel Islands, Isle of Man, Gibraltar or Falkland Islands?
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Yes
No
In the past 12 months, have you had sex with any person who has ever received human-derived clotting factor concentrates?
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Yes
No
Have you ever received human pituitary-derived growth hormone or beef-derived insulin?
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Yes
No
In the past 12 months, have you had any tissue transplantation or ever had a transplantation of cornea (covering of the eye) or dura mater (covering of the brain)?
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Yes
No
Have you or any of your blood relatives ever had Creutzfeldt-Jakob disease or been told you are at risk for it?
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Yes
No
In the past 5 years, have you used injectable (I.V.) drugs for non-medical purposes?
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Yes
No
In the past 12 months, have you had sex with someone who has used I.V. drugs?
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Yes
No
In the past 12 months, have you had sex with a man who has had sex with another man?
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Yes
No
In the past 12 months, have you had sex with any person known or suspected to have HIV infection, clinically active Hepatitis B infection or Hepatitis C infection?
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Yes
No
Provide Number In the past 6 months, how many sexual partners have you had?
In the past 5 years, have you ever had sex for money or drugs?
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Yes
No
In the past 12 months, have you been exposed to known or suspected HIV, Hepatitis B, and/or Hepatitis C through infected blood by inoculation (i.e., needle stick) or through contact with an open wound or mucous membrane such as eye or mouth?
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Yes
No
In the past 12 months, have you been held in jail, prison or correctional facility for more than 72 hours?
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Yes
No
In the past 12 months, have you had any body piercings, ear piercings, tattoos, or acupuncture in which shared instruments are known to have been used?
*
Yes
No
Have you ever been diagnosed with clinical, symptomatic or viral Hepatitis?
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Yes
No
In the past 2 months, have you had a smallpox vaccination or have you had contact with the smallpox vaccination site of another person?
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Yes
No
In the past month, have you had direct contact with a person with or suspected to have SARS or West Nile Virus?
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Yes
No
In the past 7 days, have you had a fever with a headache?
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Yes
No
In the past 14 days, have you had an open sore or infection?
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Yes
No
Have you, your partner or any member of your household ever had a transplant or medical procedure that involved being exposed to live cells, tissues or organs from an animal?
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Yes
No
I understand that I must not have any vaccination within one month of egg/sperm donation.
*
Yes
No
In the past 28 days, have you had a temperature >100.4, cough, shortness of breath, difficulty breathing, hypoxia or x-rays, indicating pneumonia or acute respiratory distress syndrome?
*
Yes
No
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