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BLOOD DONATION CAMP 14 APRIL 2021 CHIPLUN
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Email
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Your email
Name
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Your answer
Age
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Your answer
Gender
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Female
Male
Address
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Your answer
Occupation
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Your answer
Email ID
Your answer
Contact no.
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Your answer
Weight
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Below 50
50-55
Above 55
Any co-morbid condition of the following. Hypertension(HTN)/ Diabetes(DM) /, Asthma / Heart attack(MI)/Stroke Hepatitis B / HIV(AIDS) / Any major /minor surgery/dental treatment in last six months / Other/
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yes
No
Have you donated blood in last three months.
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Yes
No
Blood Group(If Known)
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Have you suffered from any Pyschological disorders ? (Dissociative Disorders ,Anxiety Disorder , Depression)
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Yes
No
Maybe
Have you taken Covid Vaccine?
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Yes
No
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