Name *

First Name

Last Name

Phone *

(###)

###

####

1. Are you in good general health? *

Yes

No

2. Have you had any recent infections, illnesses, or surgeries? *

Yes

No

3. Are you currently taking any medications? *

prescription, over-the-counter, herbal, or supplements

Yes

No

4. Do you use tobacco products or nicotine in any form? *

Yes

No

5. Do you consume alcohol? *

Yes

No

6. Have you ever used illegal drugs or misused prescription drugs? *

Yes

No

7. Have you ever tested positive for any of the following? *

HIV, Hepatitis B or C, HTLV I/II, Syphilis, CMV

Yes

No

8. Have you ever received a blood transfusion or organ transplant? *

Yes

No

9. Have you had a recent tattoo or body piercing within the past 12 months? *

Yes

No

10. Have you traveled outside the U.S. or Canada in the past 12 months? *

Yes

No

What is your baby's date of birth? *

MM

DD

YYYY

12. Is your baby healthy and growing well? *

Yes

No

13. Do you have a surplus of milk beyond your baby's needs? *

Yes

No

14. Was your baby born prematurely (before 37 weeks)? *

Yes

No

15. Have you taken any medications during pregnancy or while breastfeeding? *

Yes

No

16. Have you or your partner engaged in high-risk sexual behavior in the past year? *

Yes

No

17. Have you or your partner ever tested positive for HIV or hepatitis? *

Yes

No

18. Have you ever been incarcerated or lived with someone who was? *

Yes

No

19. Do you store pumped milk in a clean, food-grade container? *

Yes

No

Unsure

20. Do you freeze your milk immediately after pumping? *

Yes

No

21. Are you willing to follow safe milk collection and handling guidelines provided by the milk bank? *

Yes

No

I confirm the above information is accurate to the best of my knowledge. I understand that this questionnaire is part of the eligibility screening process for becoming a breast milk donor. *

By checking "Yes," you confirm that the information provided is true to the best of your knowledge and you understand this is part of the donor eligibility screening process.

Yes

Date of Signature *

MM

DD

YYYY