Personal Information

ID Status
Submission ID Submission Time
Signature Signature Date
Photo Photo (2)
Photo (3) Photo (4)
First Name Last Name
Nickname ————
Ethnicity Primary Ethnicity
Secondary Ethnicity Adopted
Member of Clubs————
Attended or Won Medal in Sports CompetitionSports Competition Details
Birth Date Age
Address City
State (Country) Email
Primary Phone Secondary Phone
Best Way to Reach Best Time to Call
Country of Citizenship Country of Birth
Emergency Contact Name Emergency Contact Phone
Marital Status ————
Spouse Name Spouse Phone Number

General Information

Prior Sperm Donor Past Sperm Donations
Last Sperm Donation Date————
Health Insured Health Insurance Provider
Sperm Donation Restriction Sperm Donation Restriction Details
Blood Type Blood RH Factor
Height (ft/inch) Height (cm)
Weight (LB) Body Shape
Natural Hair Color Eye Color
Skin Color ————
Family Genetic Disease Family Genetic Disease Details

Education and Employment

Highest Degree Earned School Name
Major Education Background
SAT Score ACT Score
GRE SCore GMAT Score
LSAT Score GPA
Plan for Further Education Plan for Further Education Details
Current Working Status Current Job Title
Current Employer Current Employer Address
Employment History ————

Medical History

Smoking Years of Smoking
Drinking How Often of Drinking
Medication Taking Medication Taking Details
Normal Naked-eye Vision Naked-eye Vision Issues
Normal Hearing Hearing Issues
Teeth Condition ————
Prior Allergy Prior Allergy Details
Prior Chronic Problem Prior Chronic Problem Details
Taken Growth Hormones Taken Growth Hormones Details
Prior Infectious Disease Infectious Disease in Past 5 Years
Infectious Disease 5 Years Ago ————
Prior Surgery Surgery in Past 5 Years
Surgery 5 Years Ago ————
Prior Hospitalization (Other than Surgery) Prior Hospitalization in Past 5 Years
Prior Hospitalization 5 Years Ago ————
Prior Mental Issue Mental Issues
Mental Treatment in Past 6 Months Mental Treatment 6 Months Ago
Prior Blood Donation Rejection Prior Blood Donation Rejection Details

Reproductive History

Any Prior Reproductive Illness Prior Reproductive Illness
Prior Reproductive Illness Treatment ————
Sexually Active Months with Current Partner
Current Relationship Monogamous Number of Partners in Past 1 Year
Any STD Partner STD Partner Details

Personality

Why Sperm Donor Aware by Family
Any Parents not Donating to Non-Donation Details
Peferred Relationship with Intended Parents Preferred Relationship Details
Self Description Personality Strength
Personality Weakness Prior Greatest Achievement
Hobbies Favorite Music
Favorite Books Favorite Sports
Favorite Food ————
Idols in Heart Reasons
Vegetarian Owning Pet
Enjoying Travel Favorite Travel Places
Languages Growing up with Languages Speaking
Exercise Exercise Details

Family — Siblings and Children

Number of Siblings Number of Brothers
Number of Sisters ————
Any Health Issue of Sibling Details of Sibling Health Issues
Number of Children ————
Any Health Issue of Children Details of Children Health Issues

Family — Parents

Mother Ethnicity Mother Alive
Mother Current/At-death Age ————
Mother Height (foot/inch) Mother Weight (LB)
Mother Blood Type Mother Blood RH Factor
Any Mother Health/Mental Issue Mother Health/Mental Issue Details
Any Mother Sibling Number of Mother Siblings
Health/Mental Issue of Mother Siblings ————
Mother Past Career ————
Father Ethnicity Father Alive
Father Current/At-death Age ————
Father Height (foot/inch) Father Weight (LB)
Father Blood Type Father Blood RH Factor
Any Father Health/Mental Issue Father Health/Mental Issue Details
Any Father Sibling Number of Father Siblings
Health/Mental Issue of Father Siblings ————
Father Past Career ————

Family — Grand Parents

Maternal Grandmother (MGM) Ethnicity MGM Alive
MGM Current/At-death Age ————
MGM Height (foot/inch) MGM Weight (LB)
MGM Blood Type MGM Blood RH Factor
Any MGM Health/Mental Issue MGM Health/Mental Issue Details
Maternal Grandfather (MGF) Ethnicity MGF Alive
MGF Current/At-death Age ————
MGF Height (foot/inch) MGF Weight (LB)
MGF Blood Type MGF Blood RH Factor
Any MGF Health/Mental Issue MGF Health/Mental Issue Details
Paternal Grandmother (PGM) Ethnicity PGM Alive
PGM Current/At-death Age ————
PGM Height (foot/inch) PGM Weight (LB)
PGM Blood Type PGM Blood RH Factor
Any PGM Health/Mental Issue PGM Health/Mental Issue Details
Paternal Grandfather (PGF) Ethnicity PGF Alive
PGF Current/At-death Age ————
PGF Height (foot/inch) PGF Weight (LB)
PGF Blood Type PGF Blood RH Factor
Any PGF Health/Mental Issue PGF Health/Mental Issue Details