KNOWN SPERM DONATION – DONOR QUESTIONNAIRE
Donor and Recipient Information
Donor Name: ________________________________________
Danish Personal Id. Number (CPR No.): _____________________________
Recipient Name: ______________________________
Recipient CPR No.: _______________
Partner's Name (if applicable): ____________________________
Partner's CPR No.: _______________
Type of Donation
☐ Known Sperm Donation
☐ Known Directed Sperm Donation
Donor Questionnaire
Pursuant to the Danish Act on Assisted Reproduction, fertility clinics are required to collect information regarding the donor's health, family medical history, and lifestyle.
The information provided in this questionnaire constitutes sensitive personal data and will be processed confidentially in accordance with applicable data protection legislation. Information will not be disclosed without your consent unless required by law.
Please answer all questions as accurately and completely as possible.
Personal Information
Family and Reproductive History
| Question | No | Yes |
|---|
| Do you currently have a spouse, registered partner, or cohabiting partner? | ☐ | ☐ |
| If yes, has your partner been informed of your intention to act as a known sperm donor? | ☐ | ☐ |
| Do you and your partner live together? | ☐ | ☐ |
| Do you have children with your current partner? | ☐ | ☐ |
| Do you have children from previous relationships? | ☐ | ☐ |
| Are all of your children in good health? | ☐ | ☐ |
| Question | No | Yes |
| Have you previously fathered a pregnancy? | ☐ | ☐ |
| Have you undergone fertility assessment or fertility treatment with a current or previous partner? | ☐ | ☐ |
| Are you biologically related to the recipient? | ☐ | ☐ |
| Are you adopted? | ☐ | ☐ |
| Have you ever donated sperm through a licensed sperm bank? | ☐ | ☐ |
| Have you previously acted as a known sperm donor? | ☐ | ☐ |
| Do you have knowledge of, and contact with, relatives on both your maternal and paternal side of the family? | ☐ | ☐ |
| Were you or either of your parents born in Africa or the Caribbean? (Required for HTLV screening assessment.) | ☐ | ☐ |
Number of children with current partner:
Number of children from previous relationships:
If any child has a medical condition, disability, congenital anomaly, or hereditary disease, please provide details:
Ethnic Origin:
Medical History
General Health
| Question | No | Yes |
| Do you consider yourself to be in good health? | ☐ | ☐ |
| Are you currently undergoing medical investigations for any illness or condition? | ☐ | ☐ |
| Do you currently take any prescription medication, over-the-counter medication, herbal remedies, or dietary supplements? | ☐ | ☐ |
| Do you regularly use pain-relieving medication, including non-prescription drugs such as ibuprofen or paracetamol? | ☐ | ☐ |
| Have you previously received medical treatment for a significant physical or psychiatric condition? | ☐ | ☐ |
| Do you have any allergies, including medication allergies? | ☐ | ☐ |
Current medication and supplements:
Allergies:
Personal Medical History
Have you ever been diagnosed with, treated for, or experienced any of the following conditions?
| Condition | No | Yes |
| Cardiovascular disease | ☐ | ☐ |
| Respiratory disease | ☐ | ☐ |
| Kidney disease or urinary tract disorders | ☐ | ☐ |
| Gastrointestinal disease | ☐ | ☐ |
| Diabetes mellitus | ☐ | ☐ |
| Thyroid or other endocrine disorders | ☐ | ☐ |
| Epilepsy or seizure disorders | ☐ | ☐ |
| Allergic disorders | ☐ | ☐ |
| Bleeding disorders or coagulation abnormalities | ☐ | ☐ |
| Infectious diseases | ☐ | ☐ |
| Cancer or malignancy | ☐ | ☐ |
| Autoimmune disorders | ☐ | ☐ |
| Sexually transmitted infections (e.g., Chlamydia, Gonorrhoea, Syphilis) | ☐ | ☐ |
| Psychiatric illness or mental health disorders | ☐ | ☐ |
If yes, please provide details:
Family Medical History
Immediate Family History*
Please indicate whether any member of your immediate family has been diagnosed with the following conditions:
| Condition | No | Yes |
| Sudden unexplained death before the age of 50 years | ☐ | ☐ |
| Intellectual disability or developmental delay | ☐ | ☐ |
| Neurological or neuromuscular disorders (e.g., Alzheimer's disease, epilepsy, muscular dystrophy) | ☐ | ☐ |
| Cancer | ☐ | ☐ |
| Severe visual impairment and/or hearing loss | ☐ | ☐ |
| Skeletal disorders, including dwarfism or craniofacial abnormalities | ☐ | ☐ |
| Down syndrome or other chromosomal abnormalities | ☐ | ☐ |
| Recurrent miscarriage or stillbirth | ☐ | ☐ |
| Cleft lip and/or palate | ☐ | ☐ |
| Spina bifida | ☐ | ☐ |
| Clubfoot | ☐ | ☐ |
| Congenital heart defects | ☐ | ☐ |
| Cystic fibrosis | ☐ | ☐ |
| Inflammatory bowel disease (e.g., Crohn's disease) | ☐ | ☐ |
| Kidney or urinary tract disease | ☐ | ☐ |
| Insulin-dependent diabetes mellitus | ☐ | ☐ |
| Thyroid disorders | ☐ | ☐ |
| Severe psychiatric disorders (e.g., schizophrenia, bipolar disorder) | ☐ | ☐ |
| More distant relatives with any of the above conditions | ☐ | ☐ |
* Immediate family includes your children, siblings and half-siblings (and their children), parents, aunts and uncles, and grandparents.
Additional Details
For each positive response, please specify:
Family member affected, diagnosis and age at diagnosis or onset:
More Distant Relatives
Please provide details of any known hereditary or significant medical conditions among more distant relatives:
Lifestyle Information
Tobacco and Nicotine Use
Do you currently smoke tobacco, cannabis, or use nicotine-containing products (including snus or nicotine pouches)?
| No | Former User (Date Stopped) | Current Use (Type and Amount) |
| ☐ | ____________________ | _____________________________ |
Alcohol Consumption
Average weekly alcohol intake:
☐ 0–2 units
☐ 3–5 units
☐ 6–10 units
☐ More than 10 units
Caffeine Consumption
Do you regularly consume caffeinated beverages or products (coffee, tea, cola, energy drinks, cocoa, etc.)?
If yes, please state the approximate daily amount:
Infectious Disease and Risk Assessment
| Question | No | Yes |
| Have you ever used recreational or illicit drugs for non-medical purposes? | ☐ | ☐ |
| Have you ever had sexual contact with a person known or suspected to be infected with HIV, Hepatitis B, or Hepatitis C? | ☐ | ☐ |
| Have you ever been exposed to blood-borne infection through a needle-stick injury or contact with potentially infectious body fluids? | ☐ | ☐ |
Physical Characteristics
Height: __________ cm
Weight: __________ kg
Donor Declaration and Consent
I declare that the information provided in this questionnaire is complete, accurate, and given to the best of my knowledge.
I confirm that I have had the opportunity to ask questions regarding the donation process and that all questions have been answered satisfactorily.
I acknowledge that I have received information regarding the legal, medical, and practical implications of the selected form of sperm donation and that my consent is given voluntarily and without coercion.
Furthermore, I acknowledge and agree that my consent will be required each time cryopreserved semen is released for use by the Fertility Clinic and each time embryos created using my sperm are thawed for treatment purposes.
I further acknowledge that sperm samples stored at Rigshospitalet will be destroyed upon completion of fertility treatment, unless otherwise agreed in writing and in accordance with applicable regulations.
Date: ____________________
Donor Signature: ________________________________________
CPR No.: ____________________
Lægelig konklusion:
| Screening | Negativ | Positiv | Analyse dato | Lægesignatur |
|---|
| Anti-HIV 1 og 2 | | | | |
|---|
| Hbs Ag | | | | |
|---|
| Anti-HBc | | | | |
|---|
| Anti-HCV | | | | |
|---|
| Syfilis | | | | |
|---|
| Klamydia (urin) | | | | |
|---|
På baggrund af det gennemførte interview samt øvrige undersøgelser vurderer jeg at, der:
| Ikke er konstateret væsentlige udelukkelsesgrunde for brug af sæddonor | |
| Er konstateret væsentlige udelukkelsesgrunde for brug af sæddonor: | |
Underskrift
Læge_________________________________________ Dato: ________________