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?	yes no
*Date of birth:
*Are you in good health?	yes no
*Please indicate your height and weight.
*Have you given blood before?	yes no
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?	yes no
If so, why?
*Have you ever had one of the following conditions:
Cancer, not including successfully treated skin or cervical carcinoma	yes no
Start date of the illness: Recovery date: Symptoms experienced:
Insulin-dependent diabetes mellitus	yes no
Start date of the illness: Recovery date: Symptoms experienced:
Heart disease or heart surgery or heart valve transplant	yes no
Start date of the illness: Recovery date: Symptoms experienced:
Chronic lung diseases or asthma treated with steroids or causing an anaphylactic reaction	yes no
Start date of the illness: Recovery date: Symptoms experienced:
Ulcerative colitis (disregard non-ulcerative colitis)	yes no
Start date of the illness: Recovery date: Symptoms experienced:
Crohn's disease	yes no
Start date of the illness: Recovery date: Symptoms experienced:
Epilepsy requiring medication and/or seizure in the past 2 years	yes no
Start date of the illness: Recovery date: Symptoms experienced:
Rheumatoid arthritis	yes no
Start date of the illness: Recovery date: Symptoms experienced:
Ankylosing spondylitis	yes no
Start date of the illness: Recovery date: Symptoms experienced:
Neurological problems	yes no
Start date of the illness: Recovery date: Symptoms experienced:
Schizophrenia or bipolar disease	yes no
Start date of the illness: Recovery date: Symptoms experienced:
Anemia with continuing iron prescription or severe symptoms	yes no
Start date of the illness: Recovery date: Symptoms experienced:
Sickle-cell, aplastic or hemolytic anemia of genetic origin	yes no
Start date of the illness: Recovery date: Symptoms experienced:
Hepatitis B or C/positive test result for hepatitis or HIV	yes no
Start date of the illness: Recovery date: Symptoms experienced:
Creutzfeldt-Jakob in a close relative	yes no
Start date of the illness: Recovery date: Symptoms experienced:

I certify that the information provided is complete and accurate to the best of my knowledge.

I have read the Guide for the Potential Donor. I understand that by joining the Stem Cell Donor Registry, I agree to give stem cells to anyone in need. I realize that if compatibility is established between me and a recipient, a subsequent decision to withdraw from the process could have deadly consequences for the patient.

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Join the Stem cell donor Registry

Medical questionnaire

*Have you ever had one of the following conditions: