Sperm Donor Questionnaire
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Date of Birth
*
-
Month
-
Day
Year
Date
Place of Birth: City/Country
*
Current Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How did you hear about Eggvise?
*
Please Select
Junette Syster
Nataly Pagano
Kilmar "Nani" Ramirez
Social Media: Facebook
Social Media: Google search
Social Media: Instagram
Personal
Are you adopted?
*
Yes
No
Ethnicity
*
Maternal Heritage
*
Paternal Heritage
*
Please indicate your religion
*
Please Select
Catholic
Christianity
Islam
Hinduism
Buddhism
Judaism
Sikhism
Height
*
Weight
*
Eye Color
*
Please Select
Brown
Hazel
Green
Blue
Natural Hair Color
*
Black
Brown
Blonde
Red
Hair Texture
*
Straight
Curly
Wavy
Complexion
*
Fair
Olive
Medium
Dark
Do you have Freckles?
*
Corrective Dental?
*
Do you currently wear glasses?
*
Marital Status
*
Single
Married
Engaged
Divorced
Widowed
Are you a US Citizen or have permeant residency?
*
Yes
No
If no, what type of visa are you on?
*
Where were you born?
*
Have you donated in the past?
*
What is your sexual orientation?
*
What is your religion?
Please Select
Catholic
Christianity
Islam
Judaism
Hinduism
Buddhism
Sikhism
Atheism
Agnosticism
Spiritual
Other
We would love to get to know you a bit more. How would you describe your personality? Tell us how you see yourself and what makes you unique. This will help future parents get to know you better and understand a little more about who you are.
*
What is your favorite type of food?*
*
Tell us, what motivates you to become an sperm donor? We would love to know more about what inspires you to make this decision
*
What amount are you seeking as compensation?
*
Education
Current level of education
*
Please Select
High school
Associate’s Degree
Bachelor’s Degree
Master’s Degree
Doctoral Degree
Name of the College currently attending or attended.
*
Major
*
If in the US, College Grade Point Average (GPA)
*
Current Ocupation
*
Do you have a learning disability?
*
Do you have any musical talents? If any, please list.
*
Do you play sports?
*
How often do you exercise? please explain.
*
How often do you exercise? please explain.
*
Please select your sexual orientation
Please Select
Heterosexual
Homosexual
Bisexual
Medical History
Are you currently sexually active?
*
Yes
No
Does your family have twins or triplets?
*
Do you follow any specific dietary preferences or restrictions that might affect your health profile?
*
Have you received a COVID-19 vaccine? If yes, please specify the type of vaccine (e.g., Pfizer, Moderna, Johnson & Johnson) and the dates of vaccination, if known.
*
How many children do you have? (if any)
*
Have you ever taken antidepressants or anxiolytics? Explain why.
*
Are you taking any prescription or over the counter medications? If yes, please explain
*
Have you been tested as a carrier of Thalassemia? If yes, please explain.
*
Have you been tested for being a Cystic Fibrosis carrier? If yes, please explain.
*
Are you currently treating any diseases? If so, please list.
*
Have you been tested as a carrier for the Sickle Cell disease? If yes, please explain
*
Have you ever had serious mental health issues?
*
Yes
No
Have you ever been diagnosed with cancer?
*
Yes
No
Have you gotten any tattoos in the past 12 months?
*
Yes
No
Have you had any piercings in the past 12 months?
*
Yes
No
Do you have any birth defects?
*
Yes
No
Have you ever been diagnosed with cancer?
*
Yes
No
Have you ever had any STI/STDs?
*
Yes
No
Have you ever had syphilis or gonorrhea?
*
Yes
No
Have you ever had hepatitis B or C?
*
Yes
No
Have you ever had a blood transfusion?
*
Yes
No
Have you ever been rejected for a blood transfusion?
*
Yes
No
Do you have any allergies?
*
Yes
No
Do you or any of your family members have a history of easily bruising or bleeding?
*
Yes
No
Have you ever had serious mental health issues?
*
Yes
No
Have you ever been clinically diagnosed with depression or bipolar disorder?
*
Yes
No
Do you have any direct family member with autism? please explain
*
Do you drink coffee? How often (daily or weekly)?
*
Do you drink alcohol? How often (daily or weekly)?
*
Do you currently use or have a history of using recreational drugs?
*
Do you smoke, vape, or use marijuana? How often (daily or weekly)?
*
Family History
Mother - Age
*
Age at death and cause of death (if applicable)
*
Health Conditions
*
Height
*
Eye Color
*
Brown
Hazel
Green
Blue
Natural Hair Color
*
Black
Brown
Red
Blonde
Occupation
*
Father- Age
*
Age at death and cause of death (if applicable)
*
Health Conditions
*
Height
*
Eye Color
*
Brown
Hazel
Green
Blue
Natural Hair Color
*
Black
Brown
Red
Blonde
Occupation
*
Maternal Grandfather - Age
*
Age at death and cause of death (if applicable)
*
Health Conditions
*
Height
*
Eye Color
*
Brown
Hazel
Green
Blue
Natural Hair Color
*
Black
Brown
Red
Blonde
Occupation
*
Maternal Grandmother - Age
*
Age at death and cause of death (if applicable)
*
Health Conditions
*
Height
*
Eye Color
*
Brown
Hazel
Green
Blue
Natural Hair Color
*
Black
Brown
Red
Blonde
Occupation
*
Paternal Grandfather - Age
*
Age at death and cause of death (if applicable)
*
Health Conditions
*
Height
*
Eye Color
*
Brown
Hazel
Green
Blue
Natural Hair Color
*
Black
Brown
Red
Blonde
Occupation
*
Paternal Grandmother - Age
*
Age at death and cause of death (if applicable)
*
Health Conditions
*
Height
*
Eye Color
*
Brown
Hazel
Green
Blue
Natural Hair Color
*
Black
Brown
Red
Blonde
Occupation
*
How many Siblings do you have?
*
Photo Uploads
Please make sure to upload at least 5 photos
Please provide 10-20 photos showcasing different life stages, including infancy, childhood, adolescence, and adulthood, along with a recent full-body photo. You may also include family photos. These images will enhance your online profile for potential parents. Aim to include photos from significant events like graduations and extracurricular activities. Minimum 10 photos required.
*
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