RCDC Blood Donation Managment System

Personal Information

Full Name

Date Of Birth

Age

Mobile

Address

City

District

Division

Police Station

Password

Do you have any allergies? If yes , then please specify bellow.

Are you currently taking medications? If yes, then please list the medications and the reasons why you are taking them.

What is your current medical condition? Do you have any communicable diseases, cardiovasscullar problemsa, diadetes, asthma etc. ?

Previous Hospitalization (Provide the reason & Tratments)

Asthma

Cardiovascular Diseases

Diabetes Mellitus

Hypertension

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I confirm that the information I provided in this document is accurate and true

I acknowledge that I have to inform my family about this registration

I allow my information to be submitted to donor registry