Sperm Donor Questionnaire
Name
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First Name
Last Name
Email
*
example@example.com
Phone Number
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-
Country Code
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Area Code
Phone Number
Date of Birth
*
-
Month
-
Day
Year
Date
Place of Birth: City/Country
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Current Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How did you hear about Eggvise?
*
Please Select
Kilmar - Nani Ramirez
Nataly Pagano
Kryssell Valoz
Alicia Ontiveros
Barbara Franklin Jardin
Social Media: Facebook
Social Media: Google search
Social Media: Instagram
Personal
Ethnicity
*
Maternal Heritage (Where is your mother from?)
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Paternal Heritage (Where is your father from?)
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Maternal Grandmother Heritage
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Maternal Grandfather Heritage
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Paternal Grandmother Heritage
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Paternal Grandfather Heritage
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Are you adopted?
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Yes
No
Are you of Jewish (genealogical) heritage?
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Yes
No
Please indicate your religion
*
Please Select
Catholic
Christianity
Islam
Hinduism
Buddhism
Judaism
Sikhism
What is your sexual orientation?
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Please Select
Heterosexual
Homosexual
Bisexual
Pansexual
Asexual
Height
*
Weight
*
Eye Color
*
Please Select
Brown
Hazel
Green
Blue
Natural Hair Color
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Black
Brown
Blonde
Red
Hair Texture
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Straight
Curly
Wavy
Complexion
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Fair
Olive
Medium
Dark
Do you have Freckles?
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Corrective Dental?
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Do you currently wear glasses?
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Marital Status
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Single
Married
Engaged
Divorced
Widowed
Are you a US Citizen or have permeant residency?
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Yes
No
If no, what type of visa are you on?
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What amount are you seeking as compensation?
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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.
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Tell us, what motivates you to become an sperm donor? We would love to know more about what inspires you to make this decision
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What is your favorite type of food?*
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If you could say something to Intended Parents, what message would you like give them?
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Have you donated in the past? If yes, how many times?
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Have you donated in the past? If yes, How many times?
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Education
Current Level of Education
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Please Select
High school
Associate’s Degree
Bachelor’s Degree
Master’s Degree
Doctoral Degree
Certificates
Name of the College/University currently attending or attended
*
Major (What Did You Study?)
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If in US, College Grade Point Average (GPA)
*
Please individually rate your aptitudes on each of the following abilities:
Poor
Average
Excellent
Mathematical/Analytical Ability
Scientific/Problem-Solving Ability
Artistic/Creative Ability(e.g., drawing, painting, design)
Athletic/Physical Ability(e.g., sports, coordination, endurance)
Current Occupation
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Do you have a learning disability?
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Please list your talents (e.g. Musical /Artistic / Athletic etc.)
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What additional language’s do you speak, read, or write?
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Do you play sports or exercise? please explain.
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How often do you exercise?
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Reproductive Health
Have you had a sperm count or fertility test in the last 12 months?
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Yes
No
What form of contraception (if any) do you typically use
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Intrauterine Device (IUD) - Copper
Birth Control Pills
Condoms
Withdrawal Method (Pull-Out)
Emergency Contraception (Morning-After Pill)
Other
Are you currently sexually active?
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Yes
No
Have you ever fathered children?
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Yes
No
If yes, how many children do you have?
How Many Children do you have?
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Yes
No
Do you have any known genetic conditions?
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Yes
No
Do you currently have or have you ever had any sexually transmitted infections (STIs)? If so, please specify if they were treated by a doctor.
*
Medical History
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.
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Yes
No
Do you follow any specific dietary preferences or restrictions that might affect your health profile?
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Yes
No
Other
Are you currently treating any diseases? If so, please list.
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Yes
No
Other
Are you taking any prescription or over the counter medications? If yes, please explain
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Yes
No
Other
Have you been tested as a carrier of Thalassemia? If yes, please explain.
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Yes
No
Other
Have you been tested for being a Cystic Fibrosis carrier? If yes, please explain.
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Yes
No
Other
Have you been tested as a carrier for the Sickle Cell disease? If yes, please explain
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Yes
No
Other
Have you gotten any tattoos in the past 12 months?
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Yes
No
Other
Have you had any piercings in the past 12 months?
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Yes
No
Other
Have you ever been diagnosed with cancer?
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Yes
No
Other
Do you have any birth defects?
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Yes
No
Other
Have you ever had any STI/STDs?
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Yes
No
Have you ever had syphilis or gonorrhea?
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Yes
No
Have you ever had hepatitis B or C?
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Yes
No
Have you ever had a blood transfusion?
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Yes
No
Have you ever been rejected for a blood transfusion?
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Yes
No
Do you or any of your family members have a history of easily bruising or bleeding?
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Yes
No
Have you ever had serious mental health issues?
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Yes
No
Have you ever been clinically diagnosed with depression or bipolar disorder?
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Yes
No
Have you ever taken antidepressants or anxiolytics? If yes, please specify
*
Do you have any allergies? If so, please specify.
*
Have you undergone any cosmetic surgeries in the past year? If so, please specify the type of surgery
*
Do you drink coffee? How often (daily or weekly)?
*
Do you drink alcohol? How often (daily or weekly)?
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Do you smoke, vape, or use marijuana? How often (daily or weekly)?
*
Does your family have twins or triplets? Please specify
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Do you or any of your family members have genetic disorders？
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Have you or any of your biological family members ever been diagnosed with cancer?(If yes, please specify the type of cancer, the family member affected, and their age at diagnosis, if known.)
Do you or any of your family members have genetic disorders？
*
Do you have any direct family member with autism? please explain
*
Family History
Mother - Current age
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Age at death and cause of death (if applicable)
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Health Conditions
*
Height
*
Eye Color
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Brown
Hazel
Green
Blue
Natural Hair Color
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Black
Brown
Red
Blonde
Occupation
*
Father - Current 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 - Current 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 - Current 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 - Current 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 - Current 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
*
Do you have siblings?
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Yes
No
How many siblings do you have in total? Please specify how many are brothers and how many are sisters.
*
Read carefully: Photo Requirements for Sperm Donor Application to complete your Sperm Donor application, you must submit 10–20 photos from different stages of your life, including: Baby pictures (required)Teenage pictures (required) Recent pictures (required)A full-body photo (required)All photos must have good lighting and no group pictures, as they help intended parents in making their decision. Bikini and lingerie photos are not permitted. This is a mandatory requirement, and applications that do not meet these guidelines may be rejected.
Please Select
I understand
Photo Uploads
MUST-HAVE PHOTO REQUIREMENTS: Please upload 15-20 clear, high-quality photos. A natural smile and modest, polished attire work best. Vibrant colors and your natural hair color will help highlight your true self. Feel free to share photos of your interests and hobbies! AVOID THESE COMMON MISTAKES: Avoid blurry, low-resolution images, exaggerated expressions, or bathroom mirror selfies. Ensure good lighting, and limit editing. No bikini pictures, please.
Baby Photos
*
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Current Photos
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I certify that all the information provided in this application is true, complete, and accurate to the best of my knowledge. I understand that providing false or misleading information may result in my disqualification from the egg donation program.
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I agree and confirm that the information provided is truthful.
Confidentiality First:Your privacy matters to us. Everything you share in this form is 100% confidential and will never be shared with anyone outside of our agency without your permission. We’re here to protect you and guide you through this process with care and respect.
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I acknowledge that the information I provide will remain confidential and will only be used internally by the agency for screening and matching purposes.
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