Table 1.

Questionnaire patient for orthopaedic bone donation

In the past 3 months, did you suffer any infection? If so, what infection?

In the past 3 months, did you have any vaccination or inoculation, or have you been injected with narcotic drugs?

In the past 6 months, did you have a malaria attack or did you use anti-malarial medication?

Have you ever been infected with a sexually transmitted disease?

Have you ever been diagnosed with jaundice or liver illness?

In the past 6 months, have you been in contact with patients diagnosed with jaundice/hepatitis?

In the past 6 months, have you been in contact with patients diagnosed with AIDS, or individuals at risk to AIDS? If yes, how and when?

Have you ever been tested for HIV/AIDS?

Have you had homosexual intercourse after 1977? (males only)

Have you emigrated after 1977? If so, to what country?

Are you diagnosed with haemophilia? If yes, are you using anticoagulants?

Are you a sexual partner of an individual for which any of the abovementioned questions can be answered with ‘yes’?

Have you been actively involved in prostitution after 1977, or have you been a sexual partner of a person involved in prostitution in the past 6 months?

Have you ever been diagnosed with a haematological disease or any malignant disorder?

Have you ever been treated for diabetes mellitus?

Have you ever been treated for chronic brain- or neurological diseases?

Have you ever received radiation therapy?

Have you ever been diagnosed with rheumatoid arthritis?

Have you ever been diagnosed with tuberculosis?

Have you ever been diagnosed with any disease, other than the abovementioned?

Have you ever received hormonal treatment?

Do you use any prescribed medication?

Have you ever used any narcotic drugs?

Have you recently been exposed to hazardous or toxic materials? If yes, please specify.

What is your alcohol consumption per week?

Have you recently been in surgery? If so, when? Did you receive blood from a blood transfusion?

In the past 14 days, have you been traveling through or staying in a region exposed to a SARS epidemic, or have you been in contact with patients infected with SARS?

In the past 6 months, have you tattooed yourself or did you get a piercing?