QC

HUMAN MILK BANK DONOR SCREENING FORM

Date______________________
Name__________________________________________________________________________________________
Surname First Name Middle Name
Date of Birth_________________________ Age_____________ Sex_________________
Home Address___________________________________________________________ Telephone______________
Office Address___________________________________________________________ Telephone______________
Occupation______________________________________________________________
Name of Child____________________________________________________________________________________
Date of Birth_____________________ Age_________ Sex__________ Birth weight____________ AOG_______
Type of Donor: ( )Community ( )Private ( )Employee ( )Network office/agency

Why do you want to donate milk? (Bakit mo gusto magbigay ng iyong gatas/breastmilk?)
_______________________________________________________________________
How did you learn about the Human Milk Bank? (Paano mo nalaman ang tungkol sa Human Milk Bank?)
_______________________________________________________________________
Please encircle your answer
Yes No

1.Are you willing to donate breast milk on a regular basis for a minimum period of 6 months?
(Gusto mo bang magbigay ng gatas nang regular sa loob ng 6 na buwan?)

Yes No

2. Will you be allowed by your husband to donate your breastmilk to the Human Milk Bank?
(Papayagan ka ba ng iyong asawa na magbigay ng iyong gatas sa Human Milk Bank?

Medical History
Yes No

1. Have you donated breast milk before? (Nakapagbigay ka na ba ng iyong gatas dati?)

Yes No

2. Have you for any reason been deferred as a milk donor?

( Ikaw ba ay natatanggihan na magbigay ng iyong gatas/breastmilk?)
If yes, for what reason?_____________________________________
(Kung oo, sa anong kadahilanan?)_____________________________

Yes No

3.Did you have a normal pregnancy and delivery for your most recent pregnancy?
(Normal ba ang panganganak mo sa huli mong anak?)

Yes No

4.Do you have any acute or chronic infection, systematic disorders, tuberculosis or history of hepatitis?
(Mayroon ka bang kahit anong impeksyon o sakit? Nagkaroon ng sakit sa atay dati?)

Yes No

5.Have you received any blood transfusion or other blood products within the last 12 months?
(Ikaw ba ay nasalinan ng dugo o kahit anung produkto mula sa dugo nitong nakaraan 12 buwan?)

Yes No

8. Do you regularly use over-the-counter medications or systematic preparations such as replacement

hormones and some birth control hormones?

Yes No

9.Do you use megadose vitamins or pharmacologically active herbal preparations?

(Gumagamit ka ba ng mga megadose vitamins o mga herbal drugs?)

Yes No

10. Are you a total vegetarian/vegan? (Ikaw ba ay hindi kumakain ng karne o isang vegetarian?)
If yes, do you supplement your diet with vitamins? ____________________
(Kung oo, umiinom ka ba ng multi-vitamins?) _________________________

Yes No

11. Do you use illicit drugs? ( Gumagamit ka ba ng ipinagbabawal na gamot?)

Yes No

12. Do you smoke? (Ikaw ba ay naninigarilyo?)

If yes, how many sticks or packs per day?______________
(Kung oo, ilang stick o pack sa isang araw?_____________

Yes No

13. Have you had breast augmentation surgery, using silicone breast implants?
(Ikaw ba ay naoperahan na sa suso at nalagyan ng silicone o artipisyal na breast implants?)

Sexual History
Yes No

1. Have you had syphilis, HIV, herpes, or any sexually-transmitted disease?

(Nagkaroon ka na ba ng mga sakit na nakukuha sa pakikipagtalik/sex?)

Yes No

2. Do you have multi sex partners?

(Nagkaroon ka na ba ng karanasang makipagtalik sa hindi lang iisang lalaki?)

Yes No

3. Have you had a sexual partner who is bisexual, promiscuous, had an STD, AIDS/HIV received blood for
a long period of time for a bleeding problem intravenous drug user?
(Nagkaroon ka ba ng partner na Nakipagtalik sa kapwa niya kauri, Nakikipagtalik sa higit isang tao,
Nagkaroon ng sakit na nakukuha sa pagtatalik gaya ng STD,AIDS/HIV, Naulit-ulit na nasalinan ng dugo,
Gumagamit ng gamot ng walang pahintulot ng doktor?)

Yes No
4. Have you had a tattoo applied or have had accidental needlestick or contact with someone elses


blood?
(Nagpalagay ka na ba ng tattoo, naturukan ng karayom nang hindi sinasadya o nadikit sa dugo ng ibang
tao?)
Donors Child
Yes No

1. Is your child healthy? (Malusog ba ang iyong anak?)

Yes No

2. Was your child delivered full term? (Ipinanganak ba ang anak mo na husto sa buwan?)

Yes No

3. Are you exclusively breastfeeding your child?

(Puro gatas mo ba ang binibigay mo sa anak mo at walang halong ibang formula/gatas?)

Yes No

4. Is/Was your youngest child jaundiced? (Madilaw/nanilaw ba ang bunso mong anak?)
If yes, at what age and for how long? ___________________
Kung oo, anong edad at gaano katagal? _________________

Yes No

5.Has your child ever received milk from another mother?

(Nakatanggap na ba ang iyong anak ng gatas/breast milk mula sa ibang ina?)
If yes, where?________________


DONORS CONSENT AND COMMITMENT FORM

I certify that I am the person being referred as a prospective milk donor to the Human Milk Bank. I have read and
understood all the entries stated above, having been explained to me in clear and understandable language. I certify
that I have answered the above questions truthfully and to the best of my knowledge.
I am donating milk in my own free will without any compensation.
I understand that I must undergo blood tests whenever necessary as part of the screening for milk donors or provide
existing blood tests I already have. I would like to be oriented on the guidelines for breast milk donation to be able to
ensure proper and clean collection of breast milk prior to its pasteurization.

DONORS SIGNATURE:____________________
WITNESS ( Saksi ):________________________

THIS PORTION IS RESERVED ONLY FOR HUMAN MILK BANK

Cough for 2 weeks
Pertinent Physical Examination

RESULT