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Sperm Donors – Potential Donor Telephone Questionnaire

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					Potential Donor Questionnaire
Andrology Laboratory 0115 9249925 ext 62749/62831

Andrology Laboratory East Block, B Floor Nottingham University Hospital (Queen’s Campus) Derby Rd NOTTINGHAM NG7 2UH

Name: Address Date of Birth Telephone

Where did you hear about us?

Web site Yes / No Poster Yes / No

Internet Yes / No Friend Yes / No

City Bus advert Yes / No Other specify)_______________

General Information Sperm donation is not a simple process with occasional samples dropped off at the clinic as with blood donation. We require commitment of usually 6-12 months, which involves time-consuming health screening and attendance for at least 20 samples. You are also required by law to be placed on a donor register in order that children born as a result of your donations may gain access to your identity (you are not in any way however financially liable for these children). You would receive compensation for each visit. Are you: 1. 2. 3. 5. 6. 7. 8. 9. Generally fit & healthy? Have a partner? Do you have any children? If yes to 4. Are they fit & healthy? Are you adopted? Do you take/Ever taken Drugs intravenously? Would you describe your sexual behaviour as: Have you ever been a sperm donor elsewhere? Heterosexual Bisexual Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Homosexual Yes / No Other?

if so, where was it?………………………………………………….and when?……………………... 11. Are your immediate family fit & healthy? Yes / No if not, give details……………………………………………………………………………………….. 12. Any birth defects in your family e.g. cleft palette, spina bifida Yes / No

Tick one of the following: I have considered the ‘information for prospective donors’ and would like to have my sample tested with a view to becoming a donor Please send me the information leaflet for further consideration Office use only: Counselled by:……………………………………….. Appointment Date:………………………………….. Date:……………………….. Time:……………………….
And.D.form.001 Version 3.0 1/10/07

Yes / No Yes / No


				
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