The Sperm Bank of California www.thespermbankofca.org

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First Name:
Last Name:
State:
City:
Email:
Phone:
Age:
Height:
Weight (pounds):
Eye Color:
Hair Color:
Are you currently employed?:
Profession:
Level of Education Completed:
Name of college attended, if any:
Are you a citizen of the United States?:	YesNo
How did you hear about us?:
Are you able to make a commitment to donate at least once a week at our Berkeley office for one year? (You must visit during lab hours, Monday through Thursday, 8:00am to 3:00pm and Friday, 8:00am to 2:00pm):	Yes No

Have you, or has anyone in your family, including your siblings, parents, aunts, uncles, first cousins and grandparents, ever had any of the following?:
Ethnic Background/Country of Origin, Mother:
Ethnic Background/Country of Origin, Father:
Are you in touch with both of your biological parents?:	Yes No
Diabetes (Type 1 or Type 2)	Yes No
Heart Disease, Heart Attack, or High Blood Pressure	Yes No
Stroke	Yes No
Cancer	Yes No
Mental Illness (Bi-Polar, Schizophrenia, Depression, etc.)	Yes No
Genetic Diseases (Alzheimer's, Sickle Cell Carrier, etc.)	Yes No
Birth Defects (spina bifida, cleft palate, heart malformation, etc.)	Yes No
Alcoholism or Substance Abuse	Yes No
Do you drink alcohol?	Yes No
If so, how many drinks per week?:
Have your sexual partners in the past five years been:	Men Women Both
Why are you interested in the program?:

The Sperm Bank of California Reproductive Technologies, Inc 2115 Milvia St., Suite 201 Berkeley, CA 94704-1157 Phone (510) 841-1858 Fax (510) 841-0332 by appointment only	Copyright © 2000 - 2009	Sitemap
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