Name: Demo
Date: Demo
Marital Status: Demo
Religion: Demo
Age: Demo
Height: Demo
Weight: Demo
Does your weight fluctuate frequently, if so how much and how often?
Demo
Body Style: Demo
Bust: Demo
Natural Hair Color: Demo
Texture: Demo
Eye Color: Demo
Complexion: Demo
Male Balding in Family? Demo
Freckles: Demo
Birth Marks: Demo
Acne? Demo
Severity: Demo
Were you adopted as an infant or child? Demo
Ethnic Origin, Paternal: Demo
Ethnic Origin, Maternal: Demo
| Family Member | Hair | Eyes | Height | Weight | Complexion |
|---|---|---|---|---|---|
| Mother | -- | -- | -- | -- | -- |
Number of Children: 0
Male: 0
Ages: 0
Female: 0
Ages: 0
Did your mother take Diethylstilbestrol (DES) during her pregnancy with you? Demo
What is your Blood type? Demo
General health: Demo
Do you have any major medical problems? Demo
Please list any condition that is not included in the list above: Demo
Are you of Jewish Ancestry? Demo
If yes, have you been tested as a carrier for Tay Sachs Disease? Demo
Result: Demo
Are you of African American ancestry? Demo
If yes, have you been tested as a carrier of Sickle Cell Anemia? Demo
Result: Demo
Are you of Mediterranean (Greek or Italian) ancestry? Demo
If yes, have you been tested as a carrier of Thalassemia? Demo
Result: Demo
Number of pregnancies: Demo
Deliveries: Demo
Miscarriages: Demo
Any Complications: Demo
Please give a brief description of the father of your children (eye, hair color, height, weight, etc) Demo
Are there any twins or multiple births in your family? Demo
Are there any twins or multiple births in your family? Demo
If yes, were they identical or fraternal? Demo
Abortions? Demo
Abortions? Demo
Miscarriages? Demo
If yes, were they identical or fraternal? Demo
Date last taken? Demo
Length of monthly cycle? Demo
Age of first menses? Demo
Dates of last three monthly cycles? Demo
Date of your last Pap smear? Demo
Result: Demo
Name of Ob/Gyn: Demo
Phone Number: Demo
Address of Ob/Gyn: Demo
Have you ever donated eggs before? Demo
If yes, Where Demo
Have you ever been a surrogate? Demo
If yes, When Demo
Have you or any of your sexual partners ever had (please mark all that apply): Demo
If you or your partner did have any of the above, was it treated by a doctor? Demo
If yes, When? Demo
Current Allergies: Demo
Please list all childhood illnesses: Demo
Please list all surgeries or hospitalizations: Demo
Vision Problems: Demo
If yes please explain: Demo
Corrective Lenses: Demo
Vision: 20/ Demo
How is your hearing? Demo
Describe any problems: Demo
Do you have healthy teeth and gums? Demo
Have you had orthodontic work in the past? Demo
Would you say that healthy teeth run in your family? Demo
Do you drink alcohol? Demo
How much? Demo
How often? Demo
Do you smoke cigarettes? Demo
How much? Demo
How often? Demo
Do you smoke marijuana? Demo
How much? Demo
How often? Demo
Have you ever used illegal drugs or non prescriptive medications? Demo
If yes, please explain: Demo
Do you engage in a regular exercise program? Demo
Type: Demo
How often? Demo
Have you ever been treated for any psychiatric illnesses? Demo
If yes, when: Demo
Why? Demo
Please rank your abilities in the following categories: Demo
Mathematical: Yes
Mechanical/Technical: Yes
Athletic: Yes
Artistic: Yes
Creativity: Yes
Musical: Yes
Social: Yes
SAT Scores: Demo
GPA: Demo
Educational Goals: Demo
Father’s Educational Background: Demo
Father’s Occupation: Demo
Mother’s Educational Background: Demo
Mother’s Occupation: Demo
Have you ever been arrested? Demo
Explain: Demo
Have you ever been convicted of a crime? Demo
Explain: Demo
Have you ever filed a lawsuit or a grievance against anyone or had one filed against you? Demo
Explain: Demo
Please describe your personality and character: Demo
List any hobbies or special interests: Demo
What do you do with your spare time? Demo
Describe your childhood (health, happiness, and personality) Demo
What were your happiest and saddest memories of childhood? Demo
What was it like growing up in your family? Demo
As a child and teenager were you attentive to rules and regulations set by authority figures, or were you mischievous and rebellious? Demo
As a teenager, would you consider yourself a leader or follower? Demo
Describe your relationship with your parents as a teen and now? Demo
Please describe your best and worst attributes about yourself: Demo
What is your philosophy on life? Demo
What goals do you have both short term and long term? Demo
Why do you want to become a donor? Demo
What message would you like to pass on to a couple who is potentially a recipient couple of your eggs? Demo
Are you willing to be an identified donor if your genetic offspring required further genetic or medical information? Demo
Are you open to meeting the recipient couple if applicable? Demo
Uploaded Photos
