Please find below a prospective Family Health History Questionnaire for historic sperm, egg and embryo donors.

This questionnaire is a template guide that you can adapt for your own purposes should you wish.

Note that the questions in the questionnaire are the types of things that Donor Conceived people may want to know.

Please note that this questionnaire was put together by one of our members who is not a medic. If you are a medic and have suggestions for changes to this questionnaire, please email us at Info@DonorConceivedUK.org.uk.

If you would like a copy of this questionnaire in Word format, regardless of how you have been impacted by historical donor conception practices (DCP, Donor, Donor Family member, Non DC Offspring, Intergenerational DCP, etc.), please email us at Info@DonorConceivedUK.org.uk.

We have had feedback that the tone of this questionnaire could be quite triggering for some donors. However, as a donor conceived person we may only have one attempt at requesting this information and then, as has happened to many DCP, the donor ceases all contact.

We do not want DCP to regret not having put EVERYTHING in the form, at the risk of something being missed. Many DCP have children they want to protect and therefore need to know as much medical family information from the donor and their family as is possible.

Disclaimer: Please note that if you are a DCP and choose to send this to your donor, you send at your own risk. Donor Conceived UK will not take any responsibility for any negative outcomes.

Section A: Donor information

Full Name: ___________________________________________

Date of Birth: ___________________ Age: _______

Current weight: _______________________ Current height: _______________________

Ethnic Background (please specify): _______________________

Country of Birth: _______________________

Section B: Immediate family members

For each blood relative, please record current age or age at death and reason for death (if deceased):

Relative	Age / Age at Death	Cause of Death (or N/A)
You	_______________________	_______________________________________________________
Mother	_______________________	_______________________________________________________
Father	_______________________	_______________________________________________________
Siblings	_______________________	_______________________________________________________
Children	_______________________	_______________________________________________________
Maternal Grandmother	_______________________	_______________________________________________________
Maternal Grandfather	_______________________	_______________________________________________________
Paternal Grandmother	_______________________	_______________________________________________________
Paternal Grandfather	_______________________	_______________________________________________________
Aunts/Uncles (list each and state which side of family they are from)		_______________________________________________________
Cousins	_______________________	_______________________________________________________

Section C: Family Medical Conditions

Please tick (✓) if you or any of your blood relatives has been diagnosed with the following conditions. If yes, please specify details of the condition including:

-Who is the family member affected (eg, sibling, cousin, aunt) and which side of family are they on?

-Age at time of their diagnosis

-The severity of the condition

-Specify if this is a known hereditary condition

1. Genetic & Chromosomal Conditions

☐ Down’s Syndrome

☐ Cystic Fibrosis

☐ Sickle Cell Disease / Trait

☐ Thalassaemia

☐ Fragile X Syndrome

☐ Muscular Dystrophy

☐ Huntington’s Disease

☐ Haemophilia / Clotting Disorders

☐ Other inherited conditions (please specify): ________________________

Details: _________________________________________

2. Neurological & Developmental

☐ Epilepsy or fits

☐ Autism Spectrum Disorder

☐ Intellectual Disability / Learning Difficulties eg, Dyslexia, dyspraxia

☐ ADHD, ADD

☐ OCD

☐ Tourette’s

☐ Schizophrenia

☐ Bipolar Disorder

☐ Alzheimer’s / Dementia

☐ Parkinson’s Disease

☐ Other neurological conditions: __________________________

Details: _________________________________________

3. Cardiovascular & Metabolic

☐ Heart Disease

☐ High Blood Pressure (Hypertension) or heart attacks

☐ High Cholesterol or lipids/fats

☐ Stroke or Mini-stroke (TIA)

☐ Diabetes (Type 1 or Type 2 – please specify)

☐ Obesity (BMI >30)

☐ Blood clots in leg or lung (thrombosis)

☐ Sudden unexplained death under age 50

☐ Any other heart defects or disorders (please give details below)

Details: _________________________________________

4. Cancer History

☐ Breast Cancer

☐ Ovarian Cancer

☐ Bowel Cancer

☐ Prostate Cancer

☐ Leukaemia / Lymphoma

☐ Other Cancers (please specify details): _______________________

Details: _________________________________________

5. Other Health Conditions

☐ Asthma, bronchitis or any other chest problems 

☐ Allergies. What are these? Please include severity and what happens at the point of a reaction?

☐ Autoimmune Disease (e.g. Lupus, Rheumatoid Arthritis, Multiple Sclerosis)

☐ Kidney Disease

☐ Liver Disease

☐ Jaundice or hepatitis

☐ Bladder conditions

☐ Severe Skin Conditions (e.g. Psoriasis, Eczema requiring hospitalisation)

☐ Hearing Loss or Blindness (congenital or early onset)

☐ Sight problems eg, lazy eye, glaucoma

☐ Ear problems eg grommets

☐ Serious reaction to general anesthetics

☐ Other serious or rare medical conditions: _________________________

Details: _________________________________________

6. Infectious Diseases

☐ Tuberculosis

☐ Hepatitis B

☐ Hepatitis C

☐ HIV / AIDS

☐ Syphilis or other sexually transmitted infections

☐ Other significant chronic infections: _________________________

Details: _________________________________________

7. Other Inherited Disorders

☐ Marfan Syndrome

☐ Ehlers-Danlos Syndrome

☐ Polycystic Kidney Disease

☐ Neurofibromatosis

☐ Tuberous Sclerosis

☐ Inherited metabolic disorders (e.g. phenylketonuria, Tay-Sachs disease, Gaucher disease)

☐ Other (please give details)

Details: _________________________________________

8. Psychiatric & Behavioural

☐ Depression (early onset or recurrent)

☐ Anxiety

☐ Substance or alcohol dependence

☐ Other (please give details)

Details: _________________________________________

9. Reproductive & Endocrine

☐ Infertility in male/female relatives

☐ Early menopause / premature ovarian failure

☐ Thyroid disease (e.g. Graves’, Hashimoto’s) or general thyroid issues (under or overactive)

☐ Other (please give details)

Details: _________________________________________

10. Gastrointestinal & Autoimmune

☐ Digestive or bowel problems

☐ Crohn’s Disease

☐ Ulcerative Colitis

☐ Coeliac Disease

☐ Other (please give details)

Details: _________________________________________

11. Congenital & Developmental

☐ Congenital malformations (e.g. cleft lip/palate, congenital heart disease)

☐ Severe skin conditions with genetic risk (e.g. albinism, xeroderma pigmentosum)

☐ Other (please give details)

Details: _________________________________________

12. Mental Health History

☐ History of suicide in first-degree relatives

☐ Other (please give details)

Details: _________________________________________

Section D: Consanguinity

Are you aware of any blood relation between your parents or grandparents (e.g. cousins marrying)?

☐ Yes

☐ No

If yes, please provide details: _________________________

Section E: Summary Declaration

I confirm that, to the best of my knowledge, the information provided above is accurate.

I also understand that withholding any information may potentially cause harm to my genetic offspring.

Signature: _________________________

Date: ___________________

Huge thanks to the DCP who put this post together.