Mount Sinai Plasma Collection Pre-Screening Questions
Thank you for your interest in donating plasma at The Mount Sinai Hospital. We have a brief questionnaire to determine if you meet the qualifications for plasma donation. Some of the questions are sensitive in nature, but it is important you answer these questions honestly.

The information will be kept private and used exclusively for donor recruitment for plasma donation.

If you have any questions or concerns regarding the screening tool, please contact sinaiplasmadonation@mountsinai.org
If you are filling out the questionnaire for someone please enter your name, otherwise leave it blank.
First Name *
Last Name *
Are you 66 years or older? *
Date of Birth *
MM
/
DD
/
YYYY
Please select your antibody titer level. Currently we are only collecting from patients who were previously tested at Mount Sinai. If you would like to have your antibodies tested, please click the link: https://forms.gle/csLWw5opWg3Ksx729 *
Please enter your phone number *
Please enter an email address *
Are you experiencing any cold, flu or respiratory symptoms? *
In the past six months have you been pregnant or are you pregnant now? *
Are you currently taking any antibiotics for an infection? *
Have you taken Plavix of Ticlid in the last 14 days? *
In the last 3 years, have you ever taken Soriatane? *
In the last 6 months have you taken Avodart or Jalyn? *
In the last month have you taken Proscar, Propecia, Absorica, Accutane, Amnesteem, Claravis, Myorisan, Sotret, Zenatane? *
Have you taken Coumadin, Effient, or Brilinta in the last 7 days? *
Have you ever had Cancer? (Exception: Skin Cancers other than Melanoma) *
Do you have a cardiac history? (Exception: Congenital Heart Disease with no ongoing concerns) *
Have you ever had Kidney Disease? (Exception: UTI or Kidney Stones) *
Have you ever had Liver Cirrhosis? *
If you have asthma, do you use a rescue inhaler regularly to control your symptoms? *
Have you ever had viral hepatitis? *
Have you ever had chronic bronchitis? *
Do you have recurrent cellulitis with more than one episode within 6 months? *
Have you ever had a stroke or Transient Ischemic Attack (TIA)? *
Have you ever had severe Chronic Obstructive Pulmonary Disease (COPD)? *
Have you ever had Rheumatoid Arthritis or Psoriatic Arthritis? *
Have you ever had a bleeding disorder? *
Have you ever had seizures? *
Have you donated whole blood or platelets in the last 8 weeks, or donated plasma in the last 7 days? *
Have you gotten a tattoo or had one touched-up in the last 12 months? This includes tattoo cover ups and permanent makeup. *
Have you received a piercing, re-piercing, gauging or piercing stretching in the last 12 months? *
In the past two weeks have you had flu-like symptoms that include fever >100.4°? *
Have you had a dental visit or tooth extraction/loss in the past 7 days? *
Have you had acupuncture in the last year? *
Have you had a transfusion in the last year? *
Are you a man that has had sex with another man in the last 12 months? *
Did you live in the UK for 3 months or more between 1980 and 1996? *
Do you have a history of prescription drug abuse or illegal drug abuse? *
A sample of my blood will be tested for infections that can be transmitted by my donation, such as Syphilis, HIV, Hepatitis B and C. *
Can we contact you for any future initiatives related to SARS CoV-2 Antibodies? *
Did you answer "Yes" to the any of the clinical questions above? (Excluding the last two questions)
Clear selection
Next
Never submit passwords through Google Forms.
This form was created inside of MSW Heart. Report Abuse