Fertinova Medical History Form For Sperm Donors 1/3 Page 2

Medical history form for sperm donors 2/3

Use of narcotic drugs:

Children or pregnancies in current or previous relationships:

Abdominal surgery:

Reproductive organ surgery:

Sexually transmitted diseases:

Other reproductive organ infections:

Mumps:

Number of sexual partners within the past six months

4 . H ER E DITARY DISEA SES I N T HE FA MI LY

Hemorrhagic disease or venous thromboses (hemophilia, etc.):

Muscular dystrophy (Duchenne, etc.):

Kidney disease (polycystic kidney disease, congenital nephrosis, etc.):

Eye diseases/blindness (retinoschisis, etc.):

Diabetes:

Other metabolic disease (alpha-1-antitrypsin deficiency, INCL, AGU, hemochromatosis, familial hypercholesterolemia, etc.):

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Parent category: Medical