Donor Registration Form

Admin

Donor Type

Donor Personality

1. Date of Birth

2. Race

3. Eye Color

4. Hair Type

5. Height (cm)

6. Weight (kg)

7. BMI

8. Body Build

Education/Social

9. Level of Education

10. Favourite Subject in School

11. Current Occupation

12. Talents and Interests

13. Favourite Color

14. Favourite Food

15. Favourite Season

16. Favourite Holiday Place

17. Total Number of Existing Children

17a. Number of Donor Children

18. Marital Status

19. Religion

Medical History

20. Do you have any allergies?

21. Chronic illnesses

22. Recurring physical symptoms not evaluated

23. Physical handicap or deformities

24. Disease traits

25. Vision without glasses

26. Wear glasses/contacts?

27. Dental problems?

28. Ever worn braces/retainer?

29. Previous surgery or complications

30. Hospitalization history

31. Major radiation/x-ray exposure?

32. Blood transfusion?

33. Tattoos?

34. Smoke cigarettes/shisha/e-cigarettes?

35. Use recreational drugs?

36. Treated for substance/alcohol abuse?

37. Partner uses drugs?

38. Multiple sexual partners?

39. Mental illness

40. Legal cases pending?

Family History

41. Race/nationality of genetic mother and father

42. Profession of genetic mother and father

43. Natural hair color of mother and father

44. Eye color of mother and father

45. Family members with diseases

46. Heritable familial cancers

Donation Preferences

47. Will you donate to couple or single persons?

48. Will you donate to mixed race couple?

49. Additional donation preferences

Photos

Childhood Photo (before age 10)

Recent Photo

All information provided is correct and pictures are all of me. I consent to participate in the Borrowdale Fertility donor program and understand the concept of anonymous donation.