Wellness Check

8669 Commodity Circle, Suite 490 • Orlando, FL 32819
Web: milkbankofflorida.org P:407-248-5050 • F: 407-370-4340 • E: INFO@milkbankofflorida.org

WELLNESS CHECK-IN

It is important that we keep in touch with you on a regular basis to learn of any concerns you may have and be attentive to your health and well-being during the time you are actively collecting milk for medically fragile babies. Kindly complete this form online and submit it to us (or print and include it) when you ship or drop off your milk.

First Name

Last Name

Donor Number

Date

1. Do you plan on continuing to donate?

Yes No

2. Do you need any supplies?

Yes No

milk collection bags (50 bags each set)

donor number stickers (80 stickers per sheet)

3. During the time you were collecting the milk to be donated have you felt unwell?

Yes No

If yes, what was the nature of the illness?

Was any over the counter or prescription medicine needed? Yes No

If yes, Name of medication & dates taken:

4. During the time you were collecting the milk to be donated have you started taking any NEW medicine on a regular basis?

Yes No

If yes, name of medication, dose & start date:

5. During the time you were collecting the milk to be donated have you taken any over the counter medications or prescription medicines?

Yes No

If yes, name of medication, dose & start date:

6. During the time you were collecting the milk to be donated have you taken any herbal remedies or supplements?

Yes No

If yes, name of supplement, dose & start date:

7. Have you been diagnosed with or suspected of having had covid-19?

Yes No

If yes, did you receive medication or infusion?

8. During the time you were collecting the milk to be donated, did anyone in your household feel unwell?

Yes No

If yes, what was the nature of the illness?

9. Have you traveled out of the country lately?

Yes No

If yes, where?

Please call or email us if you have questions or concerns. Thank you so very much for taking the time to answer these questions. We are constantly working to make sure our fragile infants receive the safest milk possible. We are so grateful for your donations.

Sincerely,
The Staff of Mothers’ Milk Bank of Florida