Simple Steps Fertility Egg Donor Application 1Tell Us About You2Family3Health4Health5Personality Full Name:(Required) Date:(Required) MM slash DD slash YYYY Marital Status:(Required) Religion:(Required) Age:(Required) Height:(Required) Weight:(Required) Does your weight fluctuate frequently, if so how much and how often?(Required) Body Style:(Required) Bust:(Required) Natural Hair Color:(Required) Texture:(Required) Eye Color:(Required) Complexion:(Required) Male Balding in Family?(Required) Freckles?(Required) Birth Marks?(Required) Acne?(Required) If so, what was the severity?(Required) Were you adopted as an infant or child?(Required) Ethnic Origin, Paternal:(Required) Ethnic Origin, Maternal:(Required) Family Member Table Family Member Hair Eyes Height Weight Complexion Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. Number of Children:(Required) Male:(Required) Ages:(Required) Female:(Required) Ages:(Required) Did your mother take Diethylstilbestrol (DES) during her pregnancy with you?(Required) What is your Blood type?(Required) General health:(Required) Do you have any major medical problems?(Required) If yes to major medical problems, please explain:(Required) Please take some time to complete this section. Carefully consider each of the following conditions. If you or any family member has (or has had) the condition, write yes and complete the line. Write no, if the condition does not exist in your family. Medical Condition Medical Condition Yes or No Which Family member and age of onset? Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. Please list any condition that is not included in the list above: Are you of Jewish Ancestry?(Required) If yes, have you been tested as a carrier for Tay Sachs Disease?(Required) If you answered yes above, what was the result?(Required) Are you of African American ancestry?(Required) If yes, have you been tested as a carrier of Sickle Cell Anemia, and if so what was the result?(Required) Are you of Mediterranean (Greek or Italian) ancestry?(Required) If yes, have you been tested as a carrier of Thalassemia, and if so what was the result?(Required) Please provide information on the deaths of immediate family membersFamily Member Family Member Age Medical Problem Age of Death Cause of Death Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. Number of pregnancies:(Required) Deliveries:(Required) Miscarriages:(Required) Any Complications:(Required) Please provide a brief description of each child:Please provide a brief description of each child: Sex Age Height Weight Eyes Hair Complexion Health Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. Please give a brief description of the father of your children (eye, hair color, height, weight, etc)(Required)Are there any twins or multiple births in your family?(Required) If yes, were they identical or fraternal?(Required) Abortions?(Required) Adoptions?(Required) Miscarriages?(Required) What type of birth control are you using?(Required) Date last taken?(Required) Length of monthly cycle?(Required) Age of first menses?(Required) Dates of last three monthly cycles?(Required) Date of your last Pap smear?(Required) Result:(Required) Name of Ob/Gyn:(Required) Phone Number:(Required) Address of Ob/Gyn:(Required) Have you ever donated eggs before?(Required) If yes, Where(Required) Have you ever been a surrogate?(Required) If yes, When(Required) Have you or any of your sexual partners ever had (please mark all that apply):Health form 1 Diseases Self Date Partner Date Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. If you or your partner did have any of the above, was it treated by a doctor?(Required) If yes, When?(Required) Current Allergies:(Required) Please list all childhood illnesses:(Required) Please list all surgeries or hospitalizations:(Required) Vision Problems:(Required) If yes please explain:(Required) Corrective Lenses:(Required) Vision: 20/(Required) How is your hearing?(Required) Describe any problems:(Required) Do you have healthy teeth and gums?(Required) Have you had orthodontic work in the past?(Required) Would you say that healthy teeth run in your family?(Required) Do you drink alcohol?(Required) How much?(Required) How often?(Required) Do you smoke cigarettes?(Required) How much?(Required) How often?(Required) Do you smoke marijuana?(Required) How much?(Required) How often?(Required) Have you ever used illegal drugs or non prescriptive medications?(Required) If yes, please explain:(Required) Do you engage in a regular exercise program?(Required) Type:(Required) How often?(Required) Have you ever been treated for any psychiatric illnesses?(Required) If yes, when:(Required) Why?(Required) Please indicate if you or anyone in your family has or has had any of the following and please provide an explanation to YES answers in the spaces provided:Untitled Diseases Yes or NO Please explain Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. Please rank your abilities in the following categories:(Required) Poor Fair Good Excellent Untitled Mathematical: Mechanical/Technical: Athletic: Artistic: Creativity: Musical: Social: Untitled Employer/Title Dates of Employment Exposures to chemical/gases Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. Describe your career goals and achievements:(Required)Untitled Education Years Completed GPA Major Degree Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. SAT Scores:(Required) GPA:(Required) Educational Goals:(Required) Father’s Educational Background:(Required) Father’s Occupation:(Required) Mother’s Educational Background:(Required) Mother’s Occupation:(Required) Have you ever been arrested?(Required) Explain:(Required) Have you ever been convicted of a crime?(Required) Explain:(Required) Have you ever filed a lawsuit or a grievance against anyone or had one filed against you?(Required) Explain:(Required) Please describe your personality and character:(Required) List any hobbies or special interests:(Required) What do you do with your spare time?(Required) Describe your childhood (health, happiness, and personality)(Required) What were your happiest and saddest memories of childhood?(Required) What was it like growing up in your family?(Required) As a child and teenager were you attentive to rules and regulations set by authority figures, or were you mischievous and rebellious?(Required)As a teenager, would you consider yourself a leader or follower?(Required) Describe your relationship with your parents as a teen and now?(Required) Please describe your best and worst attributes about yourself:(Required) What is your philosophy on life?(Required) What goals do you have both short term and long term?(Required) Why do you want to become a donor?(Required) What message would you like to pass on to a couple who is potentially a recipient couple of your eggs?(Required)Are you willing to be an identified donor if your genetic offspring required further genetic or medical information?(Required)Are you open to meeting the recipient couple if applicable?(Required) Please upload 5-10 photos(Required) Drop files here or Select files Max. file size: 2 GB, Max. files: 10. Professional Portrait Baby PIctures Family Pictures Hobbies(Camping, swimming, traveling, etc) Full Body Photos Photos of Graduations Δ
