New Fertility Center

Basic Information

First Name *

Last Name *

Date of Birth *

Have you ever donated eggs before? *

Yes No

Do you smoke or have you smoked in the past 6 months? *

Yes No

What is your preferred language? *

Are you citizen or green card holder *

Yes No

Do you have a valid Driver´s license? *

Yes No

Maternal Heritage

Paternal Heritage

Current Height *

feet

inch

cms

Current Weight *

lbs

Eye Color

Natural Hair Color

Hair Texture

Complexion

Body Type/Build

Blood Type

Race

Relationship status *

Partner information

Partner's Name

Partner's Date of Birth

What's his attitude of you being a surrogate mother

Have you or any immediate blood relative ever been diagnosed with Bi-Polar disorder or Schizophrenia? Yes No

Have you ever had thoughts of or attempted suicide? Yes No

Do you have any birth marks? Yes No

Do you have any moles/warts? Yes No

Do you currently wear glasses or contacts? Yes No

What is your prescription?

What is your dominant hand?

How far you willing to travel each way for local doctor appointments? *

Would you consider traveling outside of your area? Yes No

Education/Occupation

Level of education

Name of college currently attending or attended

Degree(s) received

College Grade Point Average(GPA)

High school Grade Point Average(GPA)

Current Occupation

Past Employment

Do you have a learning disability

Yes No

Donor Consideration

Do your parents know you are going through this experience?

Yes No

Are you willing to meet the recipient couple

Yes No

Would you prefer to remain anonymous

Yes No

Are you willing to speak with the recipients on the telephone?

Yes No

Are you comfortable participating in a Shared Cycle?

Yes No

I would donate to the following types of families

- Heterosexual couple

Yes No

- Single heterosexual mother

Yes No

- Single heterosexual father

Yes No

- Gay couple

Yes No

- Single gay mother

Yes No

- Single gay father

Yes No

- Biracial couple

Yes No

Personality

Please describe your personality

What's your biggest accomplishment

What's your favorite color

What is your favorite food

What is your favorite television show

What was your favorite subject in school

What was your least favorite subject in school

What are your hobbies

Please list any special skills, talents, or abilities you have

If you could travel anywhere, where would you goals

Who is your hero and Why

Please describe your future goals (where do you see yourself in 5 or 10 years)

Why do you want to be an egg donor

Medical History

Are you currently taking any medications/treatment (including non-prescription) Yes No

Plese describe the medication and treatment

Do you have any significant illness/injuries Yes No

Please list any significant illnesses/injuries you have had

Have you been an egg donor before? Yes No

Please provide your previous egg donation cycle records (ie: the number of cycles completed, how many eggs were retrieved, how many embryos were created, did the donation result in a positive pregnancy, was there a live birth?)

Have you had any hospitalizations and/or surgeries? Yes No

Describe hospitalizations or surgeries

Have you ever been under the care of a psychiatrist? Yes No

Describe the care of psychiatrist

Have you ever received treatment for depression? Yes No

Describe treatment for depression

Have you ever received treatment for drug/alcohol abuse? Yes No

Describe treatment for drug/alcohol abuse

Have you ever been arrested? Yes No

Describe past arrest

Do you smoke? Yes No

Describe smoke, how often and how much

Do you drink? Yes No

Describe drink, how much, how often

How often do you exercise? Yes No

Describe exercises, how much, how often

Do you have any tattoos or piercings? If yes, please explain. Yes No

Describe tattoos or piercings, and explain

Have you or your partner(s) have/had any of the following diseases?

- Chlamydia

Yes No

- HPV

Yes No

- Syphilis

Yes No

- Gonorrhea

Yes No

- Herpes

Yes No

- Venereal Warts

Yes No

- Other STD

Yes No

Have you ever had an abnormal pap smear? If so, explain. Yes No

Have you ever had prior reactive or (positive) screening for COVID-19 test? Yes No

Have you had close contact with someone who has been diagnosed with COVID-19? Yes No

Pegnancy History

Have you ever been pregnant?

Yes No

Have you ever had problems conceiving?

Yes No

Did your mother have problems conceiving?

Yes No

Was your mother given diethylstilbestrol (DES) while she was pregnant with you?

Yes No

Menstrual History

How old were you when you had your first menstrual cycle?

Do you have regular periods?

Yes No

Approximately how long in-between cycles?

Are you currently sexually active?

Yes No

Are you currently using birth control? If yes, please explain. Yes No

Genetic History

Are there any known genetic conditions or birth defects in your family? Yes No

Please describe genetic conditions or defects

Were you adopted?

Yes No

Are you of Mediterranean (Greek or Italian) ancestry?

Yes No

Are you of Jewish ancestry?

Yes No

Are you of African ancestry?

Yes No

Please list if you and/or your relatives have had any of the following

- Acne

Yes No

- ADHD/ADD

Yes No

- Alcoholism

Yes No

- Alzheimer's disease

Yes No

- Arthritis

Yes No

- Asthma

Yes No

- Autism

Yes No

- Bi-Polar disease

Yes No

- Blindness

Yes No

- Cleft lip or palate

Yes No

- Club foot

Yes No

- Color blindness

Yes No

- Cancer

Yes No

- please specify which kind

- Crohn's disease

Yes No

- Cystic Fibrosis

Yes No

- Deafness (under the age of 60)

Yes No

- Drug abuse

Yes No

- Dwarfism

Yes No

- Epilepsy

Yes No

- Endometriosis

Yes No

- Heart attack

Yes No

- Heart disease

Yes No

- Hepatitis A, B, or C

Yes No

- High Blood Pressure

Yes No

- HIV Exposure

Yes No

- Huntington's disease

Yes No

- Kidney Disease

Yes No

- Lupus

Yes No

- Leukemia

Yes No

- Mental Retardation

Yes No

- Muscular Dystrophy

Yes No

- Ovarian cysts

Yes No

- Schizophrenia

Yes No

- Sickle cell anemia

Yes No

- Spina Bifida

Yes No

- Tay Sachs disease

Yes No

- Type 1 Diabetes (Juvenile onset)

Yes No

Family members

Mother

Birth Year and Month

Is she still with us?

Yes No

Age at death and cause of death

Height

feet

inch

cms

Weight

lbs

Race

Eye Color

Natural Hair Color

Highest level of education completed

Occupation

Father

Birth Year and Month

Is he still with us?

Yes No

Age at death and cause of death

Height

feet

inch

cms

Weight

lbs

Race

Eye Color

Natural Hair Color

Highest level of education completed

Occupation

Maternal Grandmother

Birth Year and Month

Is she still with us?

Yes No

Age at death and cause of death

Height

feet

inch

cms

Weight

lbs

Race

Eye Color

Natural Hair Color

Highest level of education completed

Occupation

Maternal Grandfather

Birth Year and Month

Is he still with us?

Yes No

Age at death and cause of death

Height

feet

inch

cms

Weight

lbs

Race

Eye Color

Natural Hair Color

Highest level of education completed

Occupation

Parental Grandmother

Birth Year and Month

Is she still with us?

Yes No

Age at death and cause of death

Height

feet

inch

cms

Weight

lbs

Race

Eye Color

Natural Hair Color

Highest level of education completed

Occupation

Parental Grandfather

Birth Year and Month

Is he still with us?

Yes No

Age at death and cause of death

Height

feet

inch

cms

Weight

lbs

Race

Eye Color

Natural Hair Color

Highest level of education completed

Occupation

Siblings

How many siblings do you have? *

Birth Year and month *

Is he/she still with us?

Yes No

Age at death and cause of death

Height *

feet

inch

cms

Weight *

lbs

Ethnicity

Eye Color

Natural Hair Color

Highest level of education completed

Occupation

Insurance Information

Do you currently have health insurance?

Yes No

Insurance Company Name

Contact Information

Phone Number *

Email *

Street *

Address Line 2

City *

State/Province *

Zip Code / Postal Code *

Country *

Best time to reach you

Password *

Others

Photo

How did you hear about us?

Details of the information source

Notes

DONOR APPLICATION

Basic Information

Partner information

Education/Occupation

Donor Consideration

I would donate to the following types of families

Personality

Medical History

Have you or your partner(s) have/had any of the following diseases?

Pegnancy History

Menstrual History

Genetic History

Please list if you and/or your relatives have had any of the following

Family members

Mother

Father

Maternal Grandmother

Maternal Grandfather

Parental Grandmother

Parental Grandfather

Siblings

Insurance Information

Contact Information

Others

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