Checkout2 - Blueprint Biobank

Questionnaire

To store your cord blood and cord tissue safely, we need to ask you a few questions (33). We appreciate that some of these questions may seem very personal and sensitive. Please be assured your answers will be treated in strictest confidence.
Your answers to these questions inform how we store your cord blood and/or cord tissue, and any considerations for the suitability for future medical application.
Please indicate with a tick Yes/No your answer to the following. If you answer YES to any of the following questions, please provide further details in the section provided or below in the box indicated if more space is required.

General Health Questions

Q1.) Have you undergone egg, embryo donation or surrogacy for this pregnancy? In cases of Yes, a questionnaire is required for both the biological and birth mother.

(We will contact you soon for this second questionnaire if Yes is selected).

Yes
No

Please give details

Q2) Do you have any health problems? Please list any illnesses or conditions.

Yes
No

Please give details

Q3.) Are you currently taking any prescription medications? Please list.

Yes
No

Please give details

Q4.) Have you had any complications with this pregnancy or previous pregnancies?

Yes
No

Q5.) Have you, the biological father or anyone in your extended families, had any type of hereditary genetic disease?

Such as blood disorders (sickle cell anaemia, thalassaemia, aplastic anaemia, Fanconi’s anaemia) cancer, autoimmune diseases or other conditions of this nature.

Yes
No

Please give details

Q6.) Have you ever been told not to donate blood? Please give the reason why.

Yes
No

Please give details

Specific Health Questions

Q7.) Are you diabetic? If so, please give details of which type, including gestational diabetes.

Yes
No

Please give details

Q8.)Have you received any of the following?

a.) A corneal/scleral, ocular tissue or dura matter graft or undergone neurosurgery prior to 1992
b.) A transfusion of blood, blood products or clotting factors
c.) Any pituitary extracts from outside the UK or before 1986 in the UK (growth hormones, fertility treatment)
d.) Any bone grafts

Yes
No

Please give details

Q9.) Have you had a history of rapid progressive dementia or degenerative neurological disease?

Yes
No

Q10.) Have you or anyone in your family received cadaveric growth hormones?

Yes
No

Q11.) Have you or the biological father ever injected recreational drugs or been engaged in sexual activity for money or drugs?

Yes
No

Q12.) Have you or a member of your household ever had a medical procedure that involved being exposed to live cells from an animal?

Yes
No

Q13.) Have you been exposed to HIV/AIDs or tested positive for HIV/AIDs?

Yes
No

Q14.) Have you or anyone in your extended family been diagnosed with Creutzfeldt-Jacob Disease (CJD)?

Yes
No

Q15.) Have you been diagnosed with cancer? Please give details.

Yes
No

Please give details

Q16.) Have you ever had tuberculosis or syphilis? Please give details.

Yes
No

Please give details

Q17.) Have you ever had hepatitis? If so, please give details of which type.

Yes
No

Please give details

Q18.) Have you visited an Ebola-infected area in the last two months?

Yes
No

Q19.) In the past 3 months have you received any vaccinations (including smallpox)? Have you had contact with anyone who has received the smallpox vaccination?

Yes
No

Q20.) Have you had a medical diagnosis ZIKV (Zika virus) infection or lived/travelled to an area with active ZIKV transmission at any point during your pregnancy?

Yes
No

Q21.) Have you had sexual contact at any point during your pregnancy with a person, who in the last 6 months prior to sexual contact, has been diagnosed with ZIKV (Zika virus), or lived/travelled to an area with active ZIKV transmission?

Yes
No

In the past 6 months

Q22.) Have you had any body piercing, tattoo, acupuncture or accidental needle stick injury or contact with another individuals blood?

Yes
No

Q23.) Have you been told that you have West Nile virus (WNV) or tested positive for WNV?

Yes
No

In the past 12 months have you:

Q24.) Received an organ or stem cell transplant?

Yes
No

Q25.) Been treated for gonorrhoea or another sexually transmitted disease?

Yes
No

Q26.) Had a transplant or procedure that involved exposure to live cells, tissues or organs from an animal?

Yes
No

Q27.) Suffered from malaria or from a high fever during or after travelling outside of the UK?

Yes
No

Q28.) Been monitored due to a history of contact with an Ebola- infected individual, or other exposure to Ebola virus?

Yes
No

Q29.) Had sex with a partner who has been diagnosed with HIV, hepatitis B or hepatitis C? Or who may have had sex in parts of the world where HIV/AIDs is common?

Yes
No

Q30.) Had sex with a man who has had sex with another man?

Yes
No

Q31.) Please state the countries you have visited and resided in over the last 12 months.

Having answered all of the above questions do you have any concerns about the collection of your baby’s cord blood and cord tissue? If yes, please state below.

T’s & C’s of Signing The Form

In signing this form, you acknowledge that you are 18 or over and able to donate blood.
You certify that you have answered the above questions truthfully and to the best of your knowledge.
You certify that you have received, read and understood the educational material provided by Blueprint and have had the opportunity to ask any questions.
In some cases, based on the answers given in this health questionnaire Blueprint may recommend additional testing for infectious diseases. In most cases, this testing will only be required when the cord blood and cord tissue is requested for a medical application, Blueprint will provide details of any instances of this nature.
If the maternal health questionnaire is completed more than seven days before the date of birth, a review must be performed by the Healthcare Professional or Phlebotomist performing the collection to check you have not been exposed to infectious diseases since completing the form. This review should be documented on the procurement form included in the collection kit.

Mother's Name

First Last

Today's Date

DD

MM

YYYY

Mother's Signature

Basket

Checkout

Step 1 of 4 - Customise Your Service

Please allow yourself adequate time to complete this checkout process. You can save at any point and return to it in the next 30 days.

Total:

Mother's Details

Partner's Details

Questionnaire

General Health Questions

Specific Health Questions

In the past 6 months

In the past 12 months have you:

T’s & C’s of Signing The Form

Contract Agreement

Terms of this agreement

The following are some simple definitions which need to be understood and are deemed agreed by you

Legal ownership

Collection

Infectious Disease Testing

Storage of the cord blood and/or cord tissue

Release of the cord blood and/or cord tissue for medical application

Duration and Fees

Payment terms

Blueprint Biobank liability

Personal Information

Notices

Collection of Umbilical Cord Blood and Cord Tissue

Storage and Disposal of Umbilical Cord Blood and Cord Tissue

My Personal Data

Why we do what we do

Information

Legal