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Last name (required)
First names (required)
Personal identity code (required)
Age
Street address
Post code
City/municipality
Telephone number
E-mail
Skype address
Occupation
Account number for travel allowance
Are you in a permanent relationship?
Relationship since year (marriage, cohabitation)
Ethnic group: Finnish/something else, please specify
Height
Weight
Skin colour: white/black/something else, please specify
Hair colour: blond/light brown/dark brown/black/red
Eye colour: blue/grey/brown/green
Where did you learn about sperm donation? Please list all the places where you have heard or read about it.
Why do you want to donate sperm?
Does your partner know about your decision to become a donor?
Does your partner accept you being a donor?
Have you donated sperm before?
Have you ever had any genital diseases: inflammation/genital cancer/other, please specify.
Have you ever had: chlamydia/gonorrhoea/condyloma/other sexually transmitted disease, please specify which and when.
Which method of contraception do you use: no contraception/condom/contraceptive pill, for how many years/coil, for how many years/male sterilisation, year/female sterilisation, year/other, please specify.
If your partner has been pregnant, please provide the years of the childbirths
If your partner has been pregnant, please provide the years of miscarriages
If your partner has been pregnant, please provide the years of ectopic pregnancies
If your partner has been pregnant, please provide the years of abortions
Have any of these pregnancies begun through fertility treatments?
Have you been previously treated for infertility? Where and what kinds of treatments?
Do you have any chronic diseases? (e.g. diabetes, gastric ulcer, arterial hypertension, gastrointestinal disorders, recurrent respiratory tract infections or some other chronic disease)
Have you ever had a malignant tumour? If yes, what treatment(s) were you given: operation/radiotherapy/cytotoxins
Have you had any operations?
Do you have any allergies?
Have you previously (before this donation) had any of the following medical examinations: HIV/Hepatitis B/Hepatitis C? When was the examination performed (date) and what was the result?
Have you received any blood products during the last 12 months?
Have you or your partner been abroad during the last 6 months? If yes, where?
Do you take medications regularly? If yes, please specify.
Have you ever been given hormone therapy?
Smoking: no / yes (number of cigarettes per day)
Units of alcohol (per week, month)1 unit = 12 cl of medium alcohol content wine, 33 cl of cider/beer, 4 cl of spirits
Do you take or have you ever taken or tried drugs? If yes, what and when:
Do you or anyone in your family have any hereditary diseases or deformities? If yes, who and what kind?
Have you or anyone in your family undergone a chromosome analysis or a test for a hereditary disease? If yes, which test or analysis and what was the result?
Does anyone in your family have any of the following diseases and if yes, who: arterial hypertension, diseases of the respiratory system, diabetes, allergy, rheumatic or connective tissue diseases, kidney diseases, epilepsy/multiple sclerosis/other neurological diseases, haemorrhagic disease (e.g. haemophilia, porphyria), muscular dystrophy, cancer, mental disorders (e.g. schizophrenia, bipolar disorder), skin diseases, bone diseases, visual impairment, hearing defects, children born small or stillborn, other?
Other factors that may influence donation of sperm, and possible wishes or comments:
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