Name: (first name only, if you prefer)

City of residence:

Phone Number:

Best times to reach you:

May we leave messages at the number above? yes no

Email Address:

Preferred method of communication: phone email

Age:

Date of birth:

Height:

Weight:

Hair color:

Eye color:

Ethnicity: (ex: Caucasian)

Ethnic background: (ex: French and German)

Marital status: Single Married Domestic partner Divorced Separated

Personal Health Questions

1. Number of pregnancies (if any):

2. Date of most recent pregnancy (if any):

3. Number of children (if any):

4. Number of miscarriages (if any):

5. Current method of birth control:

6. Are your periods regular? yes no

7. How long is your monthly cycle (how long between periods)?

8. What was the date of your last PAP smear? What was the result?

For the following questions if the answer is "yes", please explain.

9. Did your mother take diethylstilbestrol (DES) or any other prescription drugs that you know of while she was pregnant with you? no yes

10. Have you ever been diagnosed with or treated for Attention Deficit Disorder (ADD) or Attention Deficit and Hyperactivity Disorder (ADHD)? no yes

11. Do you have any chronic medical condition, such as asthma, diabetes, hypothyroidism, lupus, serious allergies, or any others? no yes

12. Have you ever been hospitalized? no yes

13. Have you ever been treated for a sexually transmitted disease, including herpes, chlamydia, etc.? no yes

14. Have you ever been treated for a psychiatric disorder? (This does not include personal growth type therapy.) no yes

15. Have you ever been employed in an area where you were exposed to toxic chemicals, lead products, or radiation? no yes

16. Do you use any drugs other than small amounts of alcohol or marijuana? no yes

17. Are you currently taking any medications? If so, please indicate what they are and for what purpose they are taken. no yes

18. Do you use glasses or contact lenses? If so, since what age have you worn glasses? Do you know what your visual defect is? no yes

19. Have you experienced any learning disability? no yes

20. Have you donated previously? If so, where and when? no yes

21. Have you had a tattoo or piercing within the past year? If so, when? no yes

22. Have you spent 3 or more consecutive months anywhere in the United Kingdom between 1980 and 1996? If so, when and where? no yes

23. Have you received a blood transfusion within the last year? If so, when? no yes

24. Do you currently have health insurance? yes no

(A lack of health insurance will not disqualify you).

Family Health History

For this section the word “family” refers to you and your immediate family, grandparents, aunts, uncles, great aunts, great uncles, and cousins. It is very important that this section is filled in completely. For any question that you answer yes, please elaborate.

For each of the following relatives, please state whether they are dead or alive, their age now, or their age at the time of their death, and their cause of death. If cause of death is unknown, please state that fact. 

Aunts and Uncles:
Please list their current ages if living. If deceased, list their age at death, and cause of death.
Siblings:
Please list their current ages if living. If deceased, list their age at death, and cause of death.

1. If you know that any of your great grandparents, great aunts or uncles lived beyond the age of 80, please list their age at the time of their death.

2. Is there anyone in your family that died in infancy or childhood? If yes, please explain. no yes

3. Has any member of your family ever been born with any birth defect or illness, hereditary or congenital? no yes

4. Has anyone in your family experience any neuromuscular disorder such as Parkinson’s, ALS, multiple sclerosis, etc.? no yes

5. Has anyone in your family experienced any learning disability?  no yes

6. Has anyone in your family experienced any metabolic disorder such as diabetes, hypothyroidism, etc.? no yes

7. Has anyone in your family experienced any type of cancer? If so, please state at what age he or she was diagnosed, what type of cancer it was, and what was the outcome. no yes

8. Has anyone in your family experienced a stroke, a heart attack, high blood pressure, diabetes, or Alzheimer’s? If so please state at what age, or approximate age, this event occurred or condition was diagnosed. no yes

9. Are there any other diseases that have been experienced by anyone in your family?  no yes

10. Is there any history of alcoholism or in your family? If so, please elaborate. no yes

11. Is there any history of illegal drug use in your family? If so, please elaborate. no yes

12. Has anyone in your family ever been diagnosed with a mental illness?  no yes

13. Has anyone in your family committed suicide? no yes

Please include a photo with your application:

Thank you again for your time in responding to these questions.  We greatly appreciate your time and your willingness to share such personal information in the interests of helping a couple to realize their dream of having a baby.

When we receive your completed questionnaire, we will review it and contact you.  If you qualify to be a donor, we will send you a personality questionnaire and request that you send us one or more photo(s). After receiving the personality questionnaire, we will contact you to set up a meeting.

At that meeting we will review the procedure and the donor contract in more detail. Thank you again for your interest in possibly becoming an egg donor.