Blood Supply Safety Questionnaire

Thank you for giving blood today. In order to maintain a safe blood supply, we must ask you to fill out the following questionnaire. Many questions are personal, but will be kept in strictest confidence. You may at anytime walk out of the blood bank and no questions will be asked and your answers will NOT be kept on file or shared with your mother,
wife or daughter depending on your age. Again, thank you for donating blood. Your blood saves lives. Please answer all questions honestly using a simple yes or no. Do not prevaricate or elaborate. The computer will only accept a yes or no answer.

1. Have you ever been transfused with blood from one of your pets?
2. Is your wife or mistress a native of Gabon or Cameroon?
3. In the last five days have you suffered from night sweats or flatulence?
4. Since 1977, have you had or used a passport?
5. Have you ever been diagnosed with any of the following diseases?:
a. Piles?
b. Fallen womb or dropsy?
c. Galactose intolerance?
d. Mad Cow disease (Irate Bovine encephalitis)?
e. Myocardial infatuation?
f Rickets?
g. Lurid Spongeaform Debilitosis?
h. Alluvial depression?
i. Foaming Syndrome?
6. In the last year have you traveled or ordered online blood products from Haiti,
Gabon, Cameroun, Myanmar, Uzbekistan or Walmart?
7. In the last five days, have you been spelunking in caves frequented by livid bats
or glassy-eyed drooling primates?
8. In the last 48 days, have you had sex with any of the following:
a. A primate?
b. A clotter?
c. A civet cat?
d. A seemingly angry or unusually distraught sheep?
e. A Thai boy-girl?
f. A member of Al Qaeda?
g. A feral goat from Haiti, Gabon, Cameroun or Quebec?
9. In the last sixty days have you paid for sex with your wife or your neighbor’s wife?
10. Do you frequently exhibit symptoms?
11. Are you financially dependent on revenue from the sex trade?
12. Have you ever trafficked in exotic pets?
13. Have you ever injected bovine growth hormone?
14. Have you ever injected or inhaled beef or chicken broth from any of the following countries. Gabon, Cameroun, Britain, France, Afghanistan or Canada?

15. Have you ever had sex with, emailed or otherwise communicated with someone named Jacob Kreutsfeld?
16. To the best of your knowledge do you have SARS and do you know what it is? 17. In the last five days, have you had a fever in excess of 110 degrees fahrenheit? 18. Are you laxative dependent?
19. Are you now or have you ever been a practitioner of Haitian voodoo, Brazilian Obeia or Islamic fundamentalism?
20. Have you ever been issued a visa to Transylvania?
21. Do seemingly underachieving white tailed deer hang out in your vegetable garden?
22. Are you or have you ever been a sex object?
23. Have you ever been bitten by a mosquito that later developed gonorrhea, SARS or syphilis?
24. Have you ever had sex with a deer that was later found to have been bitten by a tick with Lyme Disease?
25. Do you walk in the woods with exposed skin?
26. Do birds act crazy on your deck and fall down dead?
27. Do you keep farm animals in your bedroom or in areas where food is prepared?
28. Have your children ever raced small turtles on food preparation areas or butcher block surfaces where salads are prepared for human consumption?
29. Is your wife or cleaning lady an undocumented sex worker?
30. Have you had plastic surgery in the last five days?
31. Do you wash your hands after evacuating your house?
32. Are you anemic, pandemic or epidemic?
33. Have you noticed any unusual parasites, cling-ons or crustacea around your offices?
34. Do you feel it is safe to share your blood with someone who may need it?

Thank you for answering honestly and ensuring our nation’s safe blood supply. All answers will remain unpublished until after your death. We will notify you by Federal Express should we find any of the above answers to have been untrue or if you have a serious disease of which you were not aware.

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