Illness and Medication Form
1. I am completing this form to:
*
Drop my milk off at Mid-Atlantic Mothers’ Milk Bank in Pittsburgh, PA
Drop my milk off at an affiliated Milk Depot
Ship my milk to the Mid-Atlantic Mothers’ Milk Bank
Not sharing milk at this time but am providing an update regarding my health and medications
Milk Depot name or location:
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ex. Mid-Atlantic Mothers' Milk Bank
2. Expected date of drop-off:
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-
Month
-
Day
Year
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3. Is this your last donation?
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Yes
No
4. Approximate amount of milk in this shipment:
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ounces
5. Approximate date range of milk in this donation:
Oldest Date:
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/
Month
/
Day
Year
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Newest Date:
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/
Month
/
Day
Year
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During the time you pumped this milk:
6. Did you take any new medications or supplement or restart an old one?
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Yes
No
If yes, name of medication or supplement:
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Start Date:
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/
Month
/
Day
Year
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End Date:
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/
Month
/
Day
Year
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7. Did you or any family member experience a significant illness?
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Yes
No
If yes, please explain significant illness details:
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8. Did you make any significant dietary changes that impact milk donation? For example, did you eliminate a food from your diet or add it back in?
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Yes
No
If yes, please explain details and dates:
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9 Are you sharing any milk collected within 12 hours of consuming alcohol?
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Yes
No
10. Did you receive vaccinations, acupuncture, tattoo, blood transfusion, tissue transplant, permanent make-up, or microblading?
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Yes
No
If yes, what procedure and when?
*
11. Is there any additional information that you’d like to share with the Milk Bank?
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Donor Name
*
First Name
Last Name
Donor Number
*
Donor Signature:
*
Use your finger or a stylus to sign.
Date:
*
/
Month
/
Day
Year
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THANK YOU FOR DONATING!!!
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