Donor History and Statement of Health

Name*

First NameLast Name

Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Email*

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Donor's date of birth*

Date

Infant's date of birth*

Date

Infant's gestation age (number of weeks) at birth*

Infant's initials*

Many milk recipients ask to send the donor a “thank you.” Are you comfortable sharing your contact information with recipients?*

YesNo

Do you or any member of your family now have (or did have at time of pumping) HIV, Hepatitis B, Hepatitis C, Syphilis, Lyme Disease, or any other serious illness? If yes, please explain below.*

YesNo

Please explain

Do you now have (or did you have at time of pumping) any known or suspected infection such as active genital or oral herpes, breast yeast, mastitis, skin sores, shingles, or any other infection? If yes, please explain below*

YesNo

Please explain

Do you consume more than 24oz of caffeinated drinks per day?*

YesNo

Do you now or did you at time of pumping smoke cigarettes or chew tobacco?*

YesNo

Do you now or did you at time of pumping use marijuana, cocaine, ecstasy, LSD, or other recreational or social substances?*

YesNo

Do you now or did you at time of pumping drink alcohol? If so, please put how many drinks per week while pumping below.*

YesNo

Please list how many drinks per week. A drink is defined as 12 oz of beer, 5 oz of wine, or 1.5 oz of distilled spirits (such as vodka, tequila, etc).

Are you now or were you at time of pumping taking any nutritional supplements or herbs, such as prenatal vitamins, iron, vitamin D, fish oil, herbal teas, fenugreek, etc.? If yes, please give names and doses of supplements and herbs you were taking*

YesNo

Please list names and doses of supplements/herbs

Are you now or were you at time of pumping taking any medications, such as hormonal contraception, an antidepressant, anti-anxiety medication, antibiotc, anti-fungal, thyroid medication, laxatives, allergy medicine, etc? If yes, please give names, doses, and dates of your medications.*

YesNo

Please list medications and doses here

In the past 12 months, have you had any vaccinations, inoculations, or shots? If yes, please explain below*

YesNo

Please list any vaccinations and when you received them. If you had the COVID vaccine, please state which brand.

In the past 12 months, have you had a sexual partner who is at high risk for HIV/AIDS, HTLV, or hepatitis (including anyone with hemophilia, anyone who has used a needle for the injection of illegal or nonprescription drugs, or anyone who has multiple sexual partners)?*

YesNo

In the past 12 months, have you had a sexual partner who has had tattoos, permanent makeup supplied with needles, ear or other body part pierced, or been accidentally stuck with a contaminated needle?*

YesNo

In the past 12 months, have you received a blood transfusion, blood products, an organ or tissue transplant, ear or body part piercing, tattooing, permanent makeup applied with needles, or an accidental stick with a contaminated needle?*

YesNo

Have you ever had a positive TB test?*

YesNo

Have you ever had acupuncture or electrolysis with non-sterile needles?*

YesNo

Have you ever injected drugs, or had an intimate relationship with someone who has injected drugs?*

YesNo

Specific lab tests are required for donors in order to screen and provide the most informed choice for recipients. Do you agree to get a one time lab draw before your first donation? Labs from pregnancy will also be accepted if they were drawn within the last year. If new labs are needed, they will be billed through your insurance. If any of the results are abnormal, Dr. Hughes will not manage these issues and you will be referred to your own physician for care. Your personal physician can also order these labs.*

YesNo

Does your insurance have a preference on where labs are drawn?

LabCorpQuestNo preference

If you need to explain any answers further, please do so here.

Please upload a picture of the front of your insurance card if labs are needed. You may also upload a screenshot of labs from pregnancy if they were within a year of milk pumped.

Please upload a picture of the back of your insurance card

If uploading insurance card, what is your relationship to the subscriber?

SelfSpouseDependent

What is your estimated milk donation?

By signing below, I confirm my understanding of and agreement with all of the following:

All informaton reported on this form is true and correct to the best of my knowledge.
The sharing of human breast milk carries inherent risks and maintaining optimal health practices, including safe handling and storage of pumped milk, is paramount. I agree to notify Dr. Hughes/Bloom Pediatrics and Lactation in the event that my health status changes, or that I discover exposure to substances, medications and/or illnesses that may make my milk unsuitable for donaton or that may have affected donated milk in the past. In the event of health status changes, I agree to refrain from donating unless cleared to do so by Dr. Hughes/Bloom Pediatrics and Lactation.

I have read and fully understand the Bloom Pediatrics and Lactation document, “Donor Guidelines for Pumping and Handling”. I have also read the Bloom Pediatrics and Lactation document, “Recipient Waiver and Release”.

I agree to avoid alcohol for at least 12 hours prior to pumping milk for donaton. I
agree to use no illegal drugs and no tobacco or nicotine for the duraton of time
I am collecting milk for donaton.

I hereby freely and voluntarily donate my milk to Bloom Pediatrics and Lactation.

Signature*

Date*

Date

Bloom Pediatrics and Lactation

All information on this form is strictly confidential and will only be seen by Dr. Hughes unless you state otherwise.