Questionnaire for Potential Sperm Donors

In order for us to process your application, please provide the following information which is required to conform with the legal requirements for donation. We appreciate some questions are of an extremely personal nature but please be assured your answers are confidential. We strongly recommend you read the sperm donation information booklet before proceeding.

I am living in the United Kingdom and I am aged between 18 and 45

YesNo

Please note that you must be able to travel Southampton on at least 18 occasions in order to donate sperm. If you are unable to do this then we will not be able to process your form.

First Name

Surname

Date of Birth

Age

Ethnicity

Country of Birth

Email address

Phone Number

Address

Postcode

Where did you hear about Complete Fertility Centre

In a few words tell us about your motivation for donating sperm

Are you adopted?

Are you donor-conceived?

Do you know your biological mother and father?

Ethnicity of biological mother

Ethnicity of biological father

Ethnicity of biological maternal grandmother

Ethnicity of biological maternal grandfather

Ethnicity of biological paternal grandmother

Ethnicity of biological paternal grandfather

Are you Jewish or of Jewish descent?

Do you consider yourself to be fit and healthy?

Do you or anyone in your immediate family (parents, grandparents, siblings, offspring) have a genetic or inherited medical illness or disorder e.g.Cleft lip, Huntington's disease, cystic fibrosis

If yes please give details

Do you or anyone in your immediate family (parents, grandparents, siblings, offspring) suffer from a serious mental or physical illness or medical condition? E.g. diabetes, epilepsy.

If yes please give details

Do you or anyone in your immediate family (parents, siblings, offspring, grandparents) suffer from or have ever suffered from a form of cancer? If yes, please list type of cancer and age of diagnosis (if known)

If yes please give details

Have you been abroad in the last 12 months?

If yes what countries did you visit?

Are you on any medication?

If yes please give details

Do you take or have you ever taken Pre-Exposure Prophylaxis (PrEP) ?

Do you have, or have you ever had any sexually transmitted diseases?

If yes, please give details

Do you or have you ever engaged in anal sex?

Do you smoke?

Do you take any illegal drugs?

If yes please give details

Have you ever been convicted of a criminal offence?

If yes please give details

Have you ever donated or applied to donate your sperm at another HFEA licensed sperm bank?

If yes please give details

Have you ever donated or applied to donate your sperm in any other context (e.g. on the internet, to a friend) in the UK or abroad?

If yes please give details

Has a woman ever become pregnant by you?

Do you have any children?

Are you able and willing to visit Complete Fertility Centre in Southampton to donate sperm on a regular basis (e.g. once per week) after 3 to 5 days of abstinence from ejaculation for a minimum of 15 times, between the hours of 8am and 11am weekdays?

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

GP Name

GP Surgery

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

Yes

Signature

What happens next?
Your completed questionnaire will be reviewed by the donor coordinator. We may contact you for more information regarding your answers. If your answers show that you meet the criteria to become a sperm donor you will be invited to attend the clinic for an initial appointment. Our preferred methods of contact are telephone and email so please ensure you have given these details at the start of this form. We will not contact your GP at this stage.

Sorry

Based on your responses we are unable to continue processing your application further