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Breastmilk Donor Health Screening Questionnaire
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Breastmilk Donor Health Screening Questionnaire
Breastmilk Donor Health Screening Questionnaire
Name
(Required)
Date of birth
(Required)
Phone
(Required)
Email
(Required)
Address
(Required)
NHI number
(Required)
The date I gave birth was
(Required)
Day
Month
Year
Consent
(Required)
I am willing to donate my surplus breastmilk.
I anticipate donating on an ongoing basis
(Required)
Yes
No
Not sure
I anticipate donating 110mls (or more) at a time
(Required)
Yes
No
Not sure
I am aware I will be screened for the following infections (routinely tested for in pregnancy); Human Immunodeficiency Virus 1&2 (HIV), Hepatitis B & C, and Syphilis. I will also be tested for Human T Cell Lymphotrophic Virus 1&2 (HTLV)
(Required)
Yes
Do you have, or ever had, any of the following:
Insulin Dependent Diabetes
(Required)
Yes
No
Any long term illness or condition that required professional follow up
(Required)
Yes
No
Any illness or infections in the last 12 months
(Required)
Yes
No
A tattoo in the last 12 months
(Required)
Yes
No
Intimate contact with anyone who, to your knowledge, has infectious hepatitis, MPox (Monkey Pox), HIV or HTLV
(Required)
Yes
No
Not sure
A blood transfusion in the previous four months
(Required)
Yes
No
A vaccination in the previous three months
(Required)
Yes
No
Have you lived in the United Kingdom, France or the Republic of Ireland between 1980 and 1996, for a cumulative six months or more?
(Required)
Yes
No
Have you travelled to other places in the world recently?
(Required)
Yes
No
If you answered yes, or were unsure about any of the questions above, please detail below.
Are you taking any of the following:
Long-term prescribed medication - tablets, creams, injections (except for the oral progesterone-only contraceptive pill, thyroxine, or an asthma inhaler) and/or antibiotics?
(Required)
Yes
No
Herbal medication preparations, eg fenugreek, dietary supplements?
(Required)
Yes
No
Growth hormones - including in the past (eg as a child)?
(Required)
Yes
No
If you had a caesarean delivery, did you require Clexane injections?
(Required)
Yes
No
If you answered yes, or were unsure about any of the questions above, please detail below.
Lifestyle:
Please identify your typical caffeine consumption
(Required)
None
1-2 beverages daily
more than 3 beverages daily
Please identify your typical alcohol consumption
(Required)
None
1-2 standard drinks, occasionally
more than 2 standard drinks per week
Please identify your typical use
(Required)
None of the following
I smoke
I vape
I use Nicotine Replacement therapy
Other people smoke/vape in the home
I use marijuana / recreational / illegal drugs
Do you follow a vegan diet?
(Required)
No
Yes
Yes and I take a Vitamin B12 supplement
If you answered yes, or were unsure about any of the questions above, please detail below.
I am aware that information collected in relation to the use of my donated breastmilk could be shared with Health NZ / Te Whatu Ora staff, and access holders, and be placed on my medical records.
(Required)
Yes
^
