Donor Interview Form

Does the milk bank have permission to leave a message on your voicemail, answering machine or with a person answering one of the above numbers?

YesNo

This information helps us identify which groups we serve well and who we need to work harder to reach.
Your answers will be kept private and will not affect your ability to donate or receive milk. Providing this information is optional.

Highest Education Completed

Race

Ethnicity: Hispanic or Latino?

Preferred Language

Baby's Information:

Donor’s Healthcare Provider (OB doctor or Midwife):

Baby’s Health Care Provider (Pediatrician, Family Doctor, Nurse Practitioner):

Were you, the baby, and other members of your household healthy during the time you collected this milk?

Yes No

Did you take prescription medications, over-the-counter medications, herbal preparations or vitamins containing herbs during the time you collected this milk?

Yes No

DONOR’S MEDICAL HISTORY

1. In the past twelve months have you had surgery or been under a doctor’s care for a major illness or participated in any clinical trials? (not related to pregnancy)

Yes No

Please describe:

3. Have you ever had jaundice, liver problems or hepatitis (not including jaundice as a newborn)?

Yes No

Please describe:

4. Have you been exposed to hepatitis A in the past 12 months or received a gamma globulin shot?

Yes No

Please describe:

5. In the past 12 months have you had sexual contact with an individual who has Hepatitis B or Hepatitis C, has ever received treatment for Hepatitis B or Hepatitis C, or has be diagnosed with any viral hepatitis?

Yes No

Please describe:

7. In the past 6 months have you had ears or body parts piercing, tattooing, or permanent makeup applied with non-sterile equipment?

Yes No

Please describe:

8. In the past 6 months have you had an accidental needle stick with a contaminated needle or received acupuncture or electrolysis with non-sterile equipment?

Yes No

Please describe:

9. Have you received a tattoo at a non-regulated site with non-singular use needles or home or prison tattoos.

Yes No

Please describe:

10. Have you had heart disease or high blood pressure (high blood pressure that continued after pregnancy)?

Yes No

Please describe:

11. Have you ever had TB, been treated for TB, a positive TB test or a chest X-ray that indicated TB?

Yes No

Please describe:

12. Have you or family members had a chronic cough lasting longer than 3 months, coughed up blood or had an unexplained fever (symptoms of TB)?

Yes No

Please describe:

15. In the past 12 months have you been diagnosed with or treated for a sexually transmitted disease (syphilis, gonorrhea, chlamydia)?

Yes No

Please describe:

16. In the past 12 months, have you had genital or oral herpes? Please provide name of antibiotic(s) and dates taken.

Yes No

Please describe:

17. In the past 12 months have you had cold sores? Please provide name and dates of any antibiotics(s) or over the counter medications taken.

Yes No

Please describe:

19. During pregnancy, after delivery, or during lactation did you receive any vaccinations or inoculations?

Yes No

Please describe:

20. In the past 56 days, have you had a smallpox vaccination or had close contact with the vaccination site of someone?

Yes No

Please describe:

21. In the past 12 months, have you had vaccinations for the exposure to rabies or received an experimental vaccine?

Yes No

Please describe:

22. Do you have a history of yeast infections (oral or vaginal or thrush of the nipple) after delivery? Please provide name of antibiotic(s) and dates taken.

Yes No

Please describe:

25. In the past 4 months, have you received a blood transfusion, blood products, organ or tissue transplant?

Yes No

Please describe:

26. Do you have a history of leukemia, lymphoma, including Hodgkin's Disease, or Kaposi sarcoma?

Yes No

Please describe:

27. Do you have a history of any cancer not listed above? If so, what type of cancer did you have?

Yes No

Please describe:

28. Have you ever received human pituitary growth hormone, dura mater (brain covering) graft, or bovine insulin?

Yes No

Please describe:

29. In the past 12 months, have you or someone you have had sexual contact with exchanged sex for money or drugs or engaged in non-prescription injection drug use?

Yes No

Please describe:

30. In the past 3 months, have you, or someone you have had sexual contact with, had a new sexual partner?

Yes No

Please describe:

31. Have you ever had intimate contact with someone who is at risk for or ever tested positive for AIDS or HIV (including anyone with hemophilia)?

Yes No

Please describe:

32. Have you had a human cadaveric dura mater transplant or brain covering graft (surgery on the brain) or have experienced or been exposed to CJD or vCJD (sometimes referred to as Mad Cow Disease)?

Yes No

Please describe:

33. While you were still pregnant, did your baby receive a blood transfusion or have surgery (in utero transfusion or surgery)?

Yes No

Please describe:

35. Has there been a case of rubella or chicken pox in your household in the past three months?

Yes No

Please describe:

36. During the time the milk was pumped did you have shingles? Milk cannot be accepted during a shingles outbreak involving the chest or breasts.

Yes No

Please describe:

37. Have you been symptomatic or tested positive for COVID-19 after delivery?

Yes No

Please describe:

38. Have you had a known exposure, developed symptoms, or been treated for Monkeypox?

Yes No

Please describe:

39. Do you believe that you have come in contact with anyone who has been diagnosed with Ebola virus?

Yes No

Please describe:

40. Have you ever traveled to Africa or plan to travel to Africa during the time you are pumping for the milk bank?

Yes No

Please describe:

DONOR HEALTH HABITS

1. MEDICATIONS: Are you or were you taking any medication (prescription or over-the-counter) such as vitamins, birth control pills, laxatives, allergy medication, vitamins with herbs, or medications or herbs to increase your milk supply during the time milk was pumped? Please list name brand of all medication, frequency taken, and date started.

Yes No

please give the names and dosages of all medications, vitamins and herbs you are/were taking. Please indicate medications and the dates taken:

2. VITAMINS/HERBS: Are you or were you taking anything to increase your milk supply?

Yes No

3. Have you taken Soriatane (acitretin) and/or Tegison (etretinate) in the last 3 years?

Yes No

Please describe:

5. Do you smoke or use tobacco products, chew nicotine gum or wear a nicotine patch?

Yes No

Please describe:

6. In the past 12 months, have you used drugs such as cocaine, ecstasy, LSD or Dexedrine?

Yes No

Please describe:

7. In the past 12 months, have you used cannabis (marijuana) either inhaled, ingested or topical, for medical or casual use?

Yes No

Please describe:

Donor’s Obstetrical and Lactation History

2. During your most recent pregnancy, delivery and post-delivery period, did you have any complications, including infection, excessive bleeding or high blood pressure?

Yes No

Please describe and provide any prescribed over the counter medications taken with dates:

The milk bank sometimes receives requests for milk from a mother on a restricted dairy diet for sensitive babies. Please let us know if you begin to eliminate dairy from your diet so we can separate this milk for those babies.

5. Was your stored breastmilk frozen within 96 hours of breastfeeding and/or pumping?

Yes No

Please describe:

6. Has any of the breastmilk you are donating been heat treated (for example: warmed, scalded, boiled) in any way prior to freezing or thawed after freezing?

Yes No

Please describe:

Baby's Medical History

2. Has your baby been exposed to any communicable diseases, such as chicken pox, mumps, etc…?

Yes No

Please describe:

3. Does your baby have frequent infections, such as colds, ear infections, diaper rash or skin infections?

Yes No

Please describe:

I understand that approval by MMBNT as a milk donor is in no way an indication that my milk is safe to share with individuals outside of the milk bank. Milk banks take multiple steps to assure the safety of donor milk beyond health screening of the donor. Therefore, I understand that my approval as a donor is not a guarantee of the safety of my milk for a recipient if it has not been processed by a HMBANA non-profit donor milk bank and may not be used to qualify me as a milk donor in any other capacity.

Yes No

I hereby certify that to the best of my knowledge I understand and have answered all questions truthfully. I have read the information provided to me regarding the spread of HIV and AIDS. I do not consider myself to be a person to be at risk for spreading HIV, AIDS or any other disease.

PERMISSION TO CONTACT HEALTHCARE PROVIDER

Donor: Please complete the information below of this form giving us permission to contact the healthcare providers.

I authorize my healthcare provider to release the requested medical information to Mothers’ Milk Bank of North Texas.

Report test results below: (used as cross reference only - if test is not preformed mark as N/A)

Mothers’ Milk Bank of North Texas
DONOR INTERVIEW

Donor's Information

Baby's Information:

Donor’s Healthcare Provider (OB doctor or Midwife):

Baby’s Health Care Provider (Pediatrician, Family Doctor, Nurse Practitioner):

DONOR’S MEDICAL HISTORY

DONOR HEALTH HABITS

Donor’s Obstetrical and Lactation History

Baby's Medical History

PERMISSION TO CONTACT HEALTHCARE PROVIDER

DONOR CONSENT FORM

Mothers’ Milk Bank of North Texas DONOR INTERVIEW

Donor's Information

Baby's Information:

Donor’s Healthcare Provider (OB doctor or Midwife):

Baby’s Health Care Provider (Pediatrician, Family Doctor, Nurse Practitioner):

DONOR’S MEDICAL HISTORY

DONOR HEALTH HABITS

Donor’s Obstetrical and Lactation History

Baby's Medical History

PERMISSION TO CONTACT HEALTHCARE PROVIDER

DONOR CONSENT FORM

Mothers’ Milk Bank of North Texas
DONOR INTERVIEW