Are you older than 18 and younger than 65? Yes No

Are you feeling ill? (cough, sore throat, flu…) Yes No

Are you pregnant or have had a baby in the last 9 months? Yes No

Are you taking any prescription medicine or treatments? Yes No

Have you ever had jaundice, hepatitis, or malaria? Yes No

Have you had any piercings or tattoos within the last year? Yes No

Have you ever received a blood transfusion? Yes No

Have you been tested positive for HIV, or think you might be at risk? Yes No

Have you ever had hepatitis or think you might have it now? Yes No

Are you a man who has ever had sex with another man? (whether protected or not)? Yes No

Have you ever been given money or drugs for sex? Yes No

Have you ever been injected with illegal drugs (including body building and cosmetics)? Yes No

Have you had sex with someone who could be HIV positive or could have hepatitis? Yes No

Do you have a serious illness, heart problems or have taken any medicine in the last 7 days? Yes No

Have you been to any medical practitioner in the past week, or waiting to visiting any soon? Yes No

Have you had contact with anyone with an infectious disease, or been vaccinated against it? Yes No

Have you ever undergone any operations? Yes No

Have you been outside the country in the past year? Yes No

How did you hear about DSC?

Please Read and Tick The Information Below

By enrolling to this Database I consent to DONNER SANG COMPTER Processing my Information. I am aware that DONNER SANG COMPTER will use my information to respond to my queries and comments and will not disclose my information to a third party.