Monday - 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.

We are very happy to assist you through the process, and to answer questions at any stage.

For the safety and security of both the donor and the babies receiving donated breastmilk, please ensure you complete this Donor Lifestyle Questionnaire honestly and as accurately as possible.

This information will be held securely and confidentially. Potential recipients will be sent your lifestyle questionnaire with your address, email and baby's name removed. Mothers Milk will not disclose this information to anyone else without your permission.

Please download and save our Donor Information PDF - let us know if you have trouble doing this, and we will email you a copy

While we prefer to match donors and recipients locally, in some cases this may not be possible. For donors, shipping may involve sourcing a polystyrene box, and business address as a pick-up location. If you have reservations or are unsure about this process, please let us know asap - ask us for guidance and more information as we are here to help facilitate your milk sharing journey. Would you like to continue?*

YesNo

No problem, click this link to be redirected to MMNZ Facebook page or simply close the window 🙂

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

Council Region

Please select from the drop down list. If you are unsure, just select unsure

Baby's Name

First NameLast Name

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

Do you smoke tobacco or vape?*

NoYes, I smoke tobaccoYes, I use a vapeOther

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

Did you live in the United Kingdom for a total of 6 months between 1980 and 1996?If yes, please provide details*

Where did you live, and when?

Do you drink coffee, energy drinks 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*

Do you have any medical / health conditions that you're aware of that requires medication?*

Such as mental health conditions and conditions like asthma, hyperthyroid, epilepsy, blood pressure etc

If or when you have a COVID19 vaccine, we need to know. This is so we can give our recipients informed consent on the milk they feed the recipient baby.

If or when you have a COVID19 vaccine, please provide us:

The brand name
The batch number
The date/s you received the first and second
A copy of your vaccine certificate/record

Have you had a COVID19 Vaccine? Please include brand of vaccine and batch number/s and date/s of your vaccination. *

We need your batch numbers in case an issue may arise with a particular batch of the vaccine, so that we can notify the milk recipient family.

Please upload a copy of your vaccine certificate/record to add to your file

Browse Files

Are you taking any medications or supplements, now or in the last month. If yes, please provide details including the dose for medications*

We need to avoid any drugs passing through donor milk to recipient babies that could cause adverse reactions. eg antibiotics causing diarrhoea or other gut health issues or other medications that can exacerbate respiratory distress or cause drowsiness etc

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 transfusion before we can process blood tests.

Have you recently had a vaccination? (in the last month) If yes, please provide details and include date of vaccine. *

Flu shot, MMR, whooping cough etc.

Do you follow recommended hand washing and equipment sterilisation practices when pumping and storing your breast milk? *

This involves 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 also require 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.

If you become unwell during your donation journey, eg cold or flu, thrush, mastitis, food poisoning or chicken pox etc please contact Mother's Milk NZ and put your milk aside until you feel well again. It is encouraged to keep feeding your own 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 5 days after finishing your medication, to assure that you are well and that the milk is safe for donation*

I understandOther

Do you have milk to share? Please estimate how much milk you currently have available to donate, and please tell us how long your milk has been in (either) a conventional fridge/freezer (3 mths max) or a chest or stand alone freezer (6 mths max). Also include the date of your earliest milk. *

MMNZ follows international milk banking guidelines for milk storage. If your milk has been stored for longer than this you can share your milk elsewhere

Are you planning to donate on an ongoing or a once off basis? For ongoing donations the time period would be 3 months until your blood tests need renewing, at which time we can review if you would like to continue. If your circumstances change during these 3 months, ie illness, please let us know. As every drop counts we do request that you keep your milk for donation through MMNZ if we have paid for your blood tests. *

It's ok to not know yet if you can give ongoing donations, you can decide later.

Please save and/or download this letter to give your GP or midwife when requesting a blood test form.

Please tell us who referred you, if you were referred to MMNZ. Or where you found MMNZ.

For example: midwife referral, word of mouth (WoM), friend's name if they are a donor or recipient (past or present), Facebook, Instagram etc

Is there anything else you would like us to know? This information helps us to match you to the most suitable recipient.

Please feel free to include how many children you have, or whether you have donated breastmilk before etc

Signature*

Today's Date*

Mother's Milk NZ Donor Lifestyle Questionnaire

Your Contact Information

Lifestyle questions

Medical and Health

Nearly finished!