Sperm donor interview

Siemennesteen lahjoittajan lomake EN

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Personal Data

Last name

First names

Personal identity code

Age

Street address

Post code

City/municipality

Email address

Phone number

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

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

Do you have biological children or have you started a pregnancy?

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?

Do you or your close relatives (your own parents, siblings or your own children) have mental health problems (e.g. bipolar disorder or schizophrenia) OR attention deficit disorder (such as ADHD or other attention deficit disorder)? If so, what?

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:

	mother	father	sister	brother	own child	grandparent
arterial hypertension
diseases of the respiratory system
diabetes
rheumatic or connective tissue diseases
kidney diseases
epilepsy
multiple sclerosis
other neurological diseases

Somewhere else:

Other factors that may influence donation of sperm, and possible wishes or comments:

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