Sperm Donors Application Form

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PERSONAL INFORMATION

Name*

First Last

Date of birth

MM slash DD slash YYYY

Ethnicity*

Nationality*

Height ( Feet)*

Hair color*

Eye color*

Skin Type*

Address*

Street Address City State / Province / Region ZIP / Postal Code Country

Telephone*

Email*

How did you hear about us? (Please specify website)

How much compensation do you expect?*

In a couple of sentences, please tell us your reasons for wishing to become a sperm donor:*

What's your hobby?*

What's your life goal?*

How was your childhood and what is your favorite memory?*

Are you adopted?*

Yes

Do you know the medical history of your biological mother and father?*

Yes

Do you consider yourself to be generally fit and healthy?*

Yes

Do you, or does anyone in your immediate family (parents, siblings, offspring), suffer from a serious mental or physical illness or medical condition?*

Yes

If yes, please give details:

To your knowledge, have you, or has anyone in your immediate family, ever been diagnosed with any of the following? (Do not worry if you do not know what some of these disorders are – you are more likely to have heard of one if someone in your family suffers from it. Please just answer as best you can.)

Albinism

Cystic fibrosis

A haemoglobin disorder

Cleft palate

Neurofibromatosis

Tuberous sclerosis

Clubfoot

Neural tube defects

Congenital hip dislocation

Hypospadias

Hypercholesterolaemia

Congenital heart malformation

Diabetes

Debilitating asthma

Severe high blood pressure

Epilepsy

Tay-Sachs disease Y /N Rheumatoid arthritis

Psychosis

Huntington’s disease

Severe eyesight problems

Thalassaemia

Sickle cell disease

Haemophilia

Glucose-6-phosphate dehydrogenase deficiency

Any kind of prion disease

Please explain

Have you visited any foreign countries in the last 24 months?*

Yes

If yes, which ones?

Are you on any medication?*

Yes

If yes, please give details:

Do you have, or have you ever had, a sexually transmitted disease?*

Yes

Having had a sexually transmitted disease in the past does not automatically exclude you from being a donor

If yes, please give details:

Have you ever taken recreational drugs intravenously?*

Yes

Do you smoke?*

Yes

If yes, how many cigarettes per day?

Have you ever been convicted of a criminal offence?*

Yes

If yes, please give details:

Have you ever donated or applied to donate your sperm?*

Yes

If yes, please give details:

Are you able to provide photo ID (driving licence or passport)?*

Yes

I confirm that I have answered this questionnaire truthfully and to the best of my knowledge.

Signature*

Date questionnaire complete*

MM slash DD slash YYYY

Sexual Partners

How many sexual partners do you currently have?*

How many sexual partners have you had in the past 6 months?*

How many sexual partners have you had in total?*

Have you had a male sexual partner in past 5 years?*

Yes

Have you ever had sex with anyone in exchange for drugs or money, or has anyone you have had sex with done the same?*

Yes

Have you ever had sex with someone suspected of HIV or viral hepatitis?*

Yes

Family Characteristics

Family Member	Eye Color	Hair Color	Skin Complexion	Height	Weight	Body Type	Education Level	Occupation
Father
Mother
Brother 1
Brother 2
Brother 3
Brother 4
Sister 1
Sister 2
Sister 3
Sister 4
Children 1
Children 2
Children 3
Children 4

FDA REQUIRED SCREENING

Have you been exposed to Zika virus in the past 4 weeks?*

Yes

Have you travelled to an area where Zika virus has been reported in the past 4 weeks?*

Yes

Have you had fever, rash, joint pain, and conjunctivitis (red eyes) in the past 4 weeks?*

Yes

Have you had sexual contact with a man/woman diagnosed with or had symptoms suggestive of Zika infection in the 3 months?*

Yes

Have you ever been sexually active with a male who was gay or bisexual?*

Yes

Have you ever injected drugs or had a sexual partner who did so?*

Yes

Have you ever had hemophilia or received any human derived clotting factor concentrates, including factor VIII or factor IX concentrate?*

Yes

Have you ever had a sexual partner with hemophilia or who received any human derived clotting factor concentrates?*

Yes

Have you ever had sex in exhange for money or drugs?*

Yes

Have you ever been sexually active with a person who has had sex in exchange for money or drugs?*

Yes

Have you ever been sexually active with a person who was known or suspected to have HIV, hepatitis B or hepatitis C?*

Yes

Have you been exposed to body fluids, open wounds, non-intact skin or mucus membranes of any person known or suspected to have HIV, hepatitis B and/or C?*

Yes

Have you had an accidental needle stick within the past 12 months?*

Yes

Have you ever been or have you had a sexual partner who was incarcerated for 72 consecutive hours or longer?*

Yes

In the past 12 months, have you lived with or had contact with anyone known or suspected to have hepatitis?*

Yes

Have you acquired a tattoo or other skin piercing procedure within the preceding 12 months?*

Yes

Have you ever been diagnosed with hepatitis?*

Yes

Have you been vaccinated or had contact with anyone vaccinated for smallpox within the past 2 months?*

Yes

Have you ever been diagnosed with or suspected to have West Nile Virus?*

Yes

Have you ever been treated for or diagnosed with chlamydia, gonorrhea, herpes or syphilis?*

Yes

Have you or any of your blood relatives been diagnosed and/or have a history of transmissible spongiform encephalopathy such as Creutzfeldt-Jakob disease or variant disease? (Mad Cow Disease)*

Yes

Have you ever received a nonsynthetic dura mater transplant or a pituitary-derived growth hormone?*

Yes

Do you have a history of changes in cognition, speech or gait?*

Yes

Have you ever received a blood transfusion?*

Yes

Have you visited or lived in the United Kingdom for three months or more between 1980-1996 including England, Scotland, Wales, Ireland, Isle of Man, Channel Islands, Gibralter or Falkland Islands?*

Yes

Were you a member of the US military, civilian military, employee or a dependent of a member of the military stationed in Belgium, the Netherlands, Germany, Spain, Portugal, Turkey, Italy or Greece between 1980-1996?*

Yes

From 1980 to present, have you spent time that adds up to 5 years or more in Europe?*

Yes

Were you born in or have you lived in any of the following Countries since 1977; Cameroon, Central Africa Republic, Chad, Congo, Equatorial, Guinea, Gabon, Niger or Nigeria?*

Yes

If yes, were you given a blood transfusion or any medical treatment with a product made from blood while you were there?

Yes

Have you ever had sexual contact with anyone who was born or lived in Cameroon, Central Africa Republic, Chad, Congo, Equatorial, Guinea, Gabon, Niger or Nigeria since 1977?*

Yes

Have you or someone you know been diagnosed, treated or suspected of having sudden acute respiratory syndrome? (SARS)*

Yes

Have you, your sexual partner, and/or anyone you live with ever had a transplant or other medical procedure that involves being exposed to live cells, tissues or organs from an animal?*

Yes

Have you been exposed to blood, saliva or fluids from the person described in the proceeding question?*

Yes

Have you ever received a human organ, tissue transplant or human extract?*

Yes

Have you ever been excluded as a blood donor?*

Yes

Have you been diagnosed or suspected to have Chagas’ disease?*

Yes

Have you been exposed to significant levels of radiation, toxic chemicals, or heavy metals (such as lead, mercury or gold) in your home or work environment?*

Yes

Have you received a bite from an animal suspected for rabies within the last six months?*

Yes

Comments

Please upload a current photo*

Accepted file types: jpg, gif, png, jpeg, Max. file size: 30 MB.

chest-up with good lighting on your face. A selfie is sufficient