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Questionnaire for blood donors regarding the occurrence of late adverse reactions to blood donation

Blood or blood component donation may cause an adverse reaction that appears several hours to days after your donation. If you have experienced any of the following symptoms related to your donation, please fill out this questionnaire. Your input will help us improve our understanding of how blood donations affect your health. Based on your feedback, we will seek effective preventive measures to reduce adverse reactions in blood donors.

First name:*

Last name:*

Personal ID no.:

Date of blood collection:

Where did you donate the blood?

At University Hospital Brno
At an off-site blood drive/temporary donation site

Type, extent, and symptoms of the reaction:

Hematoma (bruise, blood leakage, discoloration)

Late bleeding from the puncture site

Pain in the arm from which blood was drawn

Nausea without loss of consciousness

Vomiting

Nausea with loss of consciousness

- Duration of unconsciousness

Skin allergic reactions

- Localized area affected (where on the skin)

- General symptoms, describe

Phlebitis at the puncture site (may appear several days after donation)

Thrombosis (may appear up to three weeks after donation)

- Location (organ, limb)

Other (please specify)

By completing this questionnaire, I confirm the occurrence of a late adverse reaction to my blood donation.

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