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Education/Employment
Are you currently employed?
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Yes
No
Profession
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Level of Education Completed
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-Did not Complete High School-
-Complete High School-
-AA Degree in Progress-
-AA Degree Completed-
-Bachelor's Degree Completed-
-Bachelor's Degree in Progress-
-Graduate Degree in Progress-
-Graduate Degree Completed-
Name of College Attended
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Medical/Personal History
Have you donated, currently donating, or applying at another sperm bank?
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Yes
No
Have you received any tattoos or piercings in the last 12 month?
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Yes
No
Have you taken any antibiotics in the past few months?
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Yes
No
Have you ever tested positive for Hepatitis B, C, or Hepatitis of unknown etiology (cause)?
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Yes
No
Have you ever tested positive for HIV or HTLV?
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Yes
No
Have you ever had a confirmed positive test or treatment for gonorrhea, chlamydia, or syphilis in the past 12 months?
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Yes
No
Have you ever been diagnosed with genital herpes?
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Yes
No
Are you currently sexually active?
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Yes
No
Are your sexual partners/Would you sexual partners be
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-Select-
-Women-
-Men-
-Both-
How many sexual partners have you had in the past 6 months?
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How many sexual partners have you had in the past 12 months
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