Illness and Medication Form
Donor name
*
First Name
Last Name
Donor Number
*
During the time you pumped this milk . . .
Did you take any new medications or supplement or restart an old one?
*
Yes
No
If yes, name of medication or supplement:
Start Date:
/
Month
/
Day
Year
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End Date:
/
Month
/
Day
Year
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Did you or any family member experience a significant illness?
*
Yes
No
If yes, significant illness details:
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?
*
Yes
No
If yes , details and dates:
Did you consume alcohol?
*
Yes
No
If yes, did you wait at least 12 hours before pumping milk?
Yes
No
Did you or your partner receive any vaccinations, tattoo, blood transfusion, tissue transplant, permanent make-up, or microblading?
*
Yes
No
If yes, what procedure and when?
Who had the procedure?
Donor
Partner
Have you travelled out of the country since your last donation?
*
Yes
No
If yes, where and when?
Additional Information
Is this your last donation?
*
Yes
No
Would you like us to send you any breastmilk storage bags in your next box? (please mention this next time you request a box)
*
Yes
No
Amount of milk in this shipment (optional)
ounces
Newest Date (optional)
-
Month
-
Day
Year
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Oldest Date (optional)
-
Month
-
Day
Year
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Donor Signature:
*
Date:
*
/
Month
/
Day
Year
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THANK YOU FOR DONATING!!!
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