Child and Adolescent Health Service | CAHS - Donor Screening Assessment

Thank you for your interest in becoming a milk donor to the Perron Rotary Express Milk Bank (PREM Bank). To ensure donated milk is safe, we ask all donors questions relating to health and lifestyle, similar to blood donor screening. Please be accurate and honest. If you do not register or complete the assessment, no information is stored. If you do register, your information remains strictly confidential. This is a preliminary screening only.

Registration:

First name: Last name: Email: Telephone: Your date of birth Your baby's birth date In which hospital was your baby born? Please select one: I wish to donate previously expressed milk I have an oversupply and am currently expressing excess milk I am not currently expressing but have a good supply and would like to help I wish to register my interest and am currently pregnant Donating previously expressed milk Expressing excess milk Please provide any additional information relating to your current expressing regime

Have you ever:

Been declined as a blood donor for a medical reason (other than pregnancy and nursing)? Yes No Tested positive for HIV, TB or have a history of cancer? Yes No Injected drugs not prescribed by a doctor or had a sexual partner who has? Yes No

Do you currently:

Smoke or use tobacco products (including nicotine patches or gum)? Yes No Regularly consume more than one (1) standard alcoholic drink per day? Yes No Regularly consume more than 750mL (3 cups) of tea, coffee, Coke or stimulant soft drinks (such as Red Bull or Monster energy drinks) per day? Yes No

Do you currently have:

An infection of the breast, such as mastitis or thrush? Yes No Have you or a family member recently been exposed to any viral infections? Yes No Are you taking any medications or herbal preparations? Yes No Please list the medications or herbal preparations you are taking

Donor Screening Assessment

Registration:

Have you ever:

Do you currently:

In the last twelve months have you?

In the last six months have you?

In the last three months have you?

Do you currently have: