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Sperm donor interview

    Ovumia Fertinova Tampere:


    The form is sent securely using a safe connection.

    Personal Data

    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)

     

    Physical characteristics and ethnicity

    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

     

    About being a donor

    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?

     

    Genital organs

    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.

     

    Contraception

    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.

     

    Pregnancy history

    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?

     

    State of health

    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?

     

    Medication

    Do you take medications regularly? If yes, please specify.

    Have you ever been given hormone therapy?

     

    Stimulants

    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:

     

    Illnesses and diseases in your immediate family

    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:


     

      Ovumia Fertinova Helsinki:


      The form is sent securely using a safe connection.

      Personal Data

      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)

       

      Physical characteristics and ethnicity

      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

       

      About being a donor

      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?

       

      Genital organs

      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.

       

      Contraception

      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.

       

      Pregnancy history

      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?

       

      State of health

      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?

       

      Medication

      Do you take medications regularly? If yes, please specify.

      Have you ever been given hormone therapy?

       

      Stimulants

      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:

       

      Illnesses and diseases in your immediate family

      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:


       

        Ovumia Fertinova Jyväskylä:


        The form is sent securely using a safe connection.

        Personal Data

        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)

         

        Physical characteristics and ethnicity

        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

         

        About being a donor

        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?

         

        Genital organs

        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.

         

        Contraception

        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.

         

        Pregnancy history

        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?

         

        State of health

        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?

         

        Medication

        Do you take medications regularly? If yes, please specify.

        Have you ever been given hormone therapy?

         

        Stimulants

        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:

         

        Illnesses and diseases in your immediate family

        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: