Monday - Mother's Milk NZ Donor Lifestyle Questionnaire

Mother's Milk NZ Donor Lifestyle Questionnaire
Thank you for your interest in donating your breastmilk!

It truly is the most wonderful gift for a baby and the recipient whanau/family.

This form has been made available for donors and recipients to use together so they can ask lifestyle screening questions they might not otherwise realise are important for sharing breast milk.

For the safety and security of both the donor and the recipient babies, please ensure you complete this Donor Lifestyle Questionnaire honestly and as accurately as possible.
Your Contact Information
Donor Name*

First NameLast Name
Your name and contact info, if you are filling in this form on behalf of the donor. (relationship to donor would be helpful if you are comfortable letting us know, but not essential)
Donor Email*
example@example.com
Donor Phone Number*
Donor Address*

Street Address

Suburb

City

Post Code
Baby's Name

First NameLast Name
Baby's Date of Birth (or estimated due date)*

MonthDayYear
Lifestyle questions
Do you smoke tobacco or vape or use nicotine patches or gum?*

NoYes, I smoke tobaccoYes, I use a vapeYes, I use a nicotine patch or gumOther
Do you live with someone who smokes tobacco or vapes?*

NoYes, I live with someone who smokes tobaccoYes, I live with someone who vapesOther
Do you drink any alcohol or take recreational drugs?*
Please include type, amount and frequency/week
Do you drink coffee, energy drinks, green/black tea or other caffeinated drinks? If yes, please provide details.*
What type (Coffee/Coke/Energy drinks etc), how much, frequency
Do you follow a specific diet?*
Are you Vegan? Dairy free? Nut free? Gluten free? etc
Do you have sexual relations with a partner who uses needles, either recreationally or for medication? (in the last 4 months) ?*

YesNo
Have you recently been tattooed? (In the last 3 months) If yes, please provide details*
Tattoos are a risk with regards to needle use.
Medical and Health
Do you have any medical / health conditions that you're aware of that requires medication?*
Such as mental health conditions and conditions like asthma, hyper/hypothyroidism, epilepsy, blood pressure etc
Have you had a COVID19 Vaccine? Please include brand of vaccine and batch number/s and date/s of your vaccination. *
A batch number can be traced if required.
Have you recently had any other vaccinations? (in the last month) If yes, please provide details and include date of vaccine. *
Flu shot, MMR, whooping cough etc.
Are you taking any medications or supplements, now or in the last month. If yes, please provide details including the dose and frequency*
To avoid any drugs passing through donor milk to recipient babies that could cause adverse reactions. e.g. antibiotics can cause diarrhoea or gut health issues, some medications can exacerbate respiratory distress or cause drowsiness etc. Some antidepressants or anxiety medications are not compatible with milk donation. Please consult your midwife or GP.
Have you recently had a blood transfusion? (in the last 4 months). If yes, please provide details, including date of transfusion.*
As per NZ Blood Services guidelines, there is a 4-month wait period after a blood transfusion before processing blood tests.
Do you follow recommended hand washing and equipment sterilisation practices when pumping and storing your breast milk? *
Sterilising your pumping equipment after every pump session or at the end of the day, and washing your hands with warm soapy water before expressing.
During your pregnancy, did you test positive for any of the screened infectious diseases? Or have you tested positive for any other recurrent infections diseases, such as rubella or Hepatitis A?*
Hep B, HIV and syphilis are routine antenatal tests. Mother's Milk NZ recommend you include Hep C, CMV, HTLV 1&2 for milk donation as per International Milk Banking guidelines. These 6 tests need to be current and renewed every 3 months. Please read our FAQ section for further details.
If you become unwell during your milk donation journey, eg cold or flu, thrush, mastitis, food poisoning or chicken pox etc, please contact the recipient and let them know, putting your expressed milk aside until you feel well again. You can keep feeding your baby during this time, but your milk MAY NOT be ok for a recipient baby.*

I understandOther
If you need to take antibiotics, we ask that you put this milk aside until 2 days after finishing your medication, to assure that you are well and that the milk is safe for donation*

I understandOther
Nearly finished!
Do you have milk to share? Please estimate how much milk you currently have available to donate, and please tell your recipient how long your milk has been in a conventional fridge/freezer (maximum 3 months) or a chest or stand-alone freezer (6 months best practice or up to 12 months). Include the date of your earliest milk. *
Please read our FAQs to understand milk storage requirements.
Are you planning to donate on an ongoing or a one-off basis? *
It's ok to not know yet if you can give ongoing donations, you can decide later.
Do you have a specific religious/faith practice you would like to the recipient to know?
For example, Muslim's consider a milk donor's baby as a sibling of their own baby, and therefore require them to know each others baby names to prevent a future marriage.
Is there anything else you would like your recipient know?
Please feel free to include how many children you have, or whether you have donated breastmilk before etc
Signature*

Clear
Today's Date*

MonthDayYear
Should be Empty:

Mother's Milk NZ Donor Lifestyle Questionnaire

Your Contact Information

Lifestyle questions

Medical and Health

Nearly finished!