Join the Stem cell donor Registry

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Registration form
*Required fields

Medical questionnaire

   
*Are you between the ages of 18 and 35?
*Date of birth:
*Are you in good health?
*Please indicate your height and weight.
*Have you given blood before?
If so, in which year and city did you last give blood?
*Has Héma-Québec, the Canadian Blood Services or a physician ever told you NOT to give blood?
If so, why?

*Have you ever had one of the following conditions:

   
Cancer, not including successfully treated skin or cervical carcinoma
Start date of the illness: 
Recovery date: 
Symptoms experienced:
Insulin-dependent diabetes mellitus
Start date of the illness: 
Recovery date: 
Symptoms experienced:
Heart disease or heart surgery or heart valve transplant
Start date of the illness: 
Recovery date: 
Symptoms experienced:
Chronic lung diseases or asthma treated with steroids or causing an anaphylactic reaction
Start date of the illness: 
Recovery date: 
Symptoms experienced:
Ulcerative colitis (disregard non-ulcerative colitis)
Start date of the illness: 
Recovery date: 
Symptoms experienced:
Crohn's disease
Start date of the illness: 
Recovery date: 
Symptoms experienced:
Epilepsy requiring medication and/or seizure in the past 2 years
Start date of the illness: 
Recovery date: 
Symptoms experienced:
Rheumatoid arthritis
Start date of the illness: 
Recovery date: 
Symptoms experienced:
Ankylosing spondylitis
Start date of the illness: 
Recovery date: 
Symptoms experienced:
Neurological problems
Start date of the illness: 
Recovery date: 
Symptoms experienced:
Schizophrenia or bipolar disease
Start date of the illness: 
Recovery date: 
Symptoms experienced:
Anemia with continuing iron prescription or severe symptoms
Start date of the illness: 
Recovery date: 
Symptoms experienced:
Sickle-cell, aplastic or hemolytic anemia of genetic origin
Start date of the illness: 
Recovery date: 
Symptoms experienced:
Hepatitis B or C/positive test result for hepatitis or HIV
Start date of the illness: 
Recovery date: 
Symptoms experienced:
Creutzfeldt-Jakob in a close relative
Start date of the illness: 
Recovery date: 
Symptoms experienced: