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Donation Application Form NWED DONOR NUMBER __________________________________ |
Page 1 |
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UNIFORM DONOR APPLICATION FORM
Date filled out: _____/_____/_____ |
(Month/Day/Year) |
Compensation you are requesting $___________ |
To become a sperm or egg donor, we need to learn some information about your personal and medical history. Your responses to these questions will help us to make sure that your health and medical history are compatible with the donation process and in particular for egg donors that it will not involve any increased risks for you. This effort will also help us to match you to an appropriate recipient.
Please provide complete and accurate information to these questions. If you do not know the answer, ask a parent or family member. Any information you provide during the donation process, will remain completely confidential. Some of the information from this questionnaire will be given to the recipient(s) as noted but all identifying information is removed.
A “yes” response will not necessarily eliminate you as a potential donor. Most people will have at least one of these conditions in themselves or a family member. The accuracy of the information you will be giving will provide information to potential families you may help to create.
Instructions:
1.Please fill in all blanks completely. Please complete all questions and write “N/A” if not applicable.
2.Please be specific. Avoid expressions such as “natural” or “old age” (for causes of death). List any health
problems as specifically as possible. If you do not know the age, put the approximate age or ask a relative to help you. List exact relationships such as “first cousin through my mother’s sister”.
3.Please provide information on all the relatives requested. Do not write their names.
4.If you have any questions, please call your donor coordinator.
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NAME AS IT APPEARS ON YOUR DRIVER’S LICENSE |
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Last name: __________________________ |
First name: ___________________ Middle Initial: _____ |
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Sex: Male ______ Female ______ |
Age: _______ |
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Date of Birth: ____/____/____ Place of Birth:_________________ |
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Soc. Security #: ______-______-________ |
Are you a US citizen or permanent resident? Yes |
No |
Driver’s License #:______________________ |
State:__________ |
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Marital Status: ____single ____married ____ divorced ____ widowed ______engaged _____partnered
Length of Current Relationship: _____ years
Nation Wide Egg Donation Application 08/2011
Donation Application Form NWED DONOR NUMBER __________________________________ |
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DEMOGRAPHICS
MAILING ADDRESS:
Street: __________________________________________________City: ______________________________
State/Province: ____________ Zip/ Postal code: _______________ Country: ______________
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OK to leave message? |
Home Phone Number: |
( |
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Yes |
No |
Work Phone Number: |
( |
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Yes |
No |
Cell Phone Number: |
( |
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Yes |
No |
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Email Address: |
__________________________________________________ |
Do you have medical insurance? ____Yes |
____No |
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If yes, name of carrier: ____________ |
ID #:______________ |
Group #__________________ |
Employer: ________________________________________________________________________________________
DONATION HISTORY:
Have you applied or been screened to be an egg or sperm donor before? ____Yes ____No
If yes, list name and location of donor program (s): _____________________________________________________
_________________________________________________________________________________________________
Have you donated before? ____Yes ____No If yes, how many times did you donate or cycle? ____
Are you currently enrolled as an egg or sperm donor in another program? ____Yes ____No
How did you hear about our program?
Radio (which station)_________________ |
Friend (name)______________________ |
Newspaper (which one) _______________ Magazine (which one)___________________
Website (which one) ________________ |
Other (specify)____________________ |
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Did you consult with your family when completing your family medical history? _____Yes |
_____No |
I hereby attest that all information disclosed in this application is accurate, true, and up-to-date to the best of my
knowledge. ___________________________________________________________________________
(Signature of Applicant)
Nation Wide Egg Donation Application 08/2011
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Donation Application Form NWED DONOR NUMBER __________________________________ |
Page 3 |
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PERSONAL HEALTH HISTORY
Are you currently under a physicians care for any reason? _____Yes _____No
If yes, please explain: ________________________________________________________________________
Have you ever had any major illnesses such as amoebic dysentery (infection of the intestine), hypertension, blood clots, pneumonia, mononucleosis, etc.? ____Yes ____No
If yes, when? _______________________________________________________________________________
Have you had any serious illness in the past? _____ Yes _____ No
If yes, please describe: ______________________________________________________________________________
Did you have any complications or concerns with anesthesia? _______________________________________________
Have you had any hospitalization(s) not mentioned above? _________________________________________________
_________________________________________________________________________________________________
Please list any surgical procedures:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Have you ever had any broken bones? _____Yes _____ No If yes, please list: _____________________________
How many days in the preceding 12 months did you miss work because of illness (colds, flu, accidents, surgery, etc.)? Please explain:____________________________________________________________________________________
Has anyone in your family, including yourself, experienced recurring and/or chronic physical symptoms that have not been evaluated by a physician (Please include those symptoms that you may not consider serious.)? _____Yes _____No
If yes, please describe:______________________________________________________________________________.
Have you ever been seen by psychiatrist, psychologist, social worker, counselor, or any other mental health professional for any reason? ____Yes _____No
If yes, when, for how long and for what reason? ____________________________________________________
Have you ever used medications such as antianxiety or antidepressants to treat an emotional or psychological problem?
____Yes ____No
If yes, list why and date last used _______________________________________________________________
Have you been vaccinated in the last 6 months? _____Yes _____No
If yes, what were you vaccinated for? ___________________________________________________________
List all medications that you have taken in the proceeding 12 months (prescription):
Medication |
How Often |
Reason |
____________________ |
_________ |
_____________________________________________ |
____________________ |
_________ |
_____________________________________________ |
____________________ |
_________ |
_____________________________________________ |
____________________ |
_________ |
_____________________________________________ |
Nation Wide Egg Donation Application 08/2011
Donation Application Form NWED DONOR NUMBER __________________________________ Page 4
PERSONAL HEALTH HISTORY (continued)
List all current over-the-counter medications (include hormones, vitamins, aspirin, antacids, laxatives, herbal & sports
supplements, performance-enhancing supplements including steroids, etc.) |
Medication |
How Often |
Reason |
____________________ |
_________ |
_____________________________________________ |
____________________ |
_________ |
_____________________________________________ |
____________________ |
_________ |
_____________________________________________ |
____________________ |
_________ |
_____________________________________________ |
Have you ever taken anti-malarial drugs or had malaria? |
_____Yes |
_____No |
Have you had a blood transfusion? |
_____Yes |
_____No |
If yes, when? _______________ |
Have you ever been refused or denied as a blood donor? _____Yes |
_____No If yes, why? ____________________ |
Are you eligible to work in the United States? _____Yes |
____No |
Is your work schedule flexible? ____Yes ____No |
List all the jobs you held in the past five years: |
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Have you had radiation exposure or x-ray exposure? _____Yes _____No
If yes, please explain: ________________________________________________________________________
Have you ever been exposed to “agent orange” or any other herbicides or chemicals (military, forestry, highway service,
or elsewhere)? _____Yes |
_____No |
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If yes, which substance(s)? ____________________________________________________________________ |
When? __________________________________ |
Where? ______________________________________ |
In the preceding six months, were you exposed to the following in your job, living environment or while involved in hobbies? If yes to any of these, give dates and how often you have been exposed. Please consider carefully.
Exposed to: |
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When? |
How Often? |
Toxic Chemicals or Substances |
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Yes |
No |
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Sprays |
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Yes |
No |
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Fumes/Exhaust |
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Yes |
No |
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Radiation |
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Yes |
No |
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Flea Powder/Sprays |
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Yes |
No |
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Lead/Lead products |
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Yes |
No |
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Asbestos/Asbestos products |
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Yes |
No |
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Pesticides/Herbicides |
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Yes |
No |
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Cleaning solutions/solvents |
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Yes |
No |
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Nation Wide Egg Donation Application 08/2011
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Donation Application Form NWED DONOR NUMBER __________________________________ |
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PERSONAL HEALTH HISTORY (continued)
Do you take hot baths, saunas, hot tubs, or steam baths? _____Daily _____Weekly _____Occasionally _____Never
Within the past 6 months have you been exposed to UV rays in a tanning booth? _____ Yes |
_____ No |
What is your caffeine usage? Number cups of coffee: _____ Soda _____ Tea _____ Energy Drinks _____ |
Do you currently smoke cigarettes? Daily |
Occasionally Rarely |
Never If yes, how many per day? _____ |
Have you ever smoked cigarettes? ____Yes ____No |
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If yes, how many cigarettes per day? __________ |
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If no, what year/month did you stop? __________ |
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How many years did you smoke? _____ |
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What best describes your alcohol consumption? ____Never drink |
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____ Rarely drink/Drink in small amounts |
____Even amounts through the week ____Drink in concentrated periods |
What type of alcohol do you usually consume? _____Beer _____ Wine _____Liquor |
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If you do drink, how many drinks do you usually consume in a week? |
____1-3 ____4-9 ____10-15 ____16 or more |
Have you ever used recreational or illicit drugs (cocaine, marijuana, LSD, heroin, barbiturates, narcotics, opiates, |
amphetamines, hallucinogens, tranquilizers, PCP, steroids, or etc.)? |
_____ Yes _______ No |
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If yes, which one (s) and when did you last use them? _______________________________________________ |
Do you sleep well? _____Yes _____ No |
If no, how do you manage this?__________________________________ |
Have you had acupuncture, ear and/or body piercing or tattooing in which sterile procedures may not have been used?
____Yes _____No
Please list and describe all of your tattoos and body piercings:
Date Received: |
Description: |
Location on Body: |
Sterile Needles Used? |
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Have you ever had any problems with the law (i.e. DUI, custody issues, lawsuits)? _____Yes _____No
If yes, please explain _________________________________________________________________________
Please list any arrests, convictions, sentences, etc.: ________________________________________________
__________________________________________________________________________________________
Have you ever been incarcerated? If yes, please describe__________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Nation Wide Egg Donation Application 08/2011
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Donation Application Form NWED DONOR NUMBER __________________________________ |
Page 6 |
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SEXUAL AND CONTRACEPTIVE HISTORY
Sexual Orientation (please circle): Homosexual Heterosexual Bisexual
Number of current sexual partners: ______Number of sexual partners during the last six months: ______
Total number of past sexual partners: ______
In the last 6 months have you had unprotected sex (intercourse without a condom) with a new partner? ___Yes ___No
Have you ever injected drugs or had a sexual partner who did so? ____Yes ____No |
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CONTRACEPTIVE HISTORY: |
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Currently use: IUD Type _____ |
Diaphragm _____ |
Condom _____ |
Birth Control Pills _____ |
Rhythm _____ Spermicide _____ Depo-Provera _____ Tubal Ligation _____ None _____ |
If Birth Control Pills: __________________________ (name) |
How long on Birth Control Pills? ___________________ |
Why did you start taking Birth Control Pills? ___________________________ |
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If Depo-Provera, when was your last injection? _________________________
To your knowledge, have you or any of your sexual partners been in contact with anyone or have you been personally tested or been treated for any of the following:
Self |
Partner If yes, when: How many times? When was the last time? |
HIV (AIDS)
NSU (non specific urethritis)
Syphilis
Gonorrhea
Chlamydia
Trichomonas
Venereal Warts
Herpes, Genital
Viral Hepatitis B or C
Genital Sores
Penis Discharge
Other sexually transmissible diseases
Nation Wide Egg Donation Application 08/2011
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Donation Application Form NWED DONOR NUMBER __________________________________ |
Page 7 |
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MENSTRUAL AND REPRODUCTIVE HISTORY: FOR EGG DONORS |
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Age at onset of menses: _______ |
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Date of Last Menstrual Period: ____________ |
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Are your menstrual periods regular: _____Yes |
_____No |
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How long is your monthly cycle (first day of one period to first day of the next)? ________days |
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Are you periods regular when you are not on any type of hormonal birth control such as the pill, etc.? ____Yes |
____ No |
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If no, how many times per year do you menstruate? ___________ |
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How many days does your period usually last? ______ days |
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Do you bleed or spot between periods? _____Yes _____No |
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Do you get menstrual cramps before, during, or after your period? ____Yes ____No |
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If yes, are your cramps: mild |
moderate |
severe? |
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If yes, do you use medication alleviate the pain? _____Yes |
_____No |
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If yes, what medications do you use? ____________________________________________________________
Have you ever had any medical treatment for menstrual problems? ___________________________________________
Date of last Pap Smear: ________________ Result: ____________________________________________________
Have you ever had an abnormal PAP: __________________ If yes, when & why: _______________________________
Have you ever been told you were infertile: ______________ If yes, when & why:________________________________
Have you ever had a pelvic infection requiring treatment with antibiotics ____Yes ____No
Do you want children in the future? ____Yes ____No
REPRODUCTIVE HISTORY (or partner for sperm donors)
FERTILITY HISTORY: |
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Number of pregnancies:___________________ |
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Number of miscarriages: __________________ |
Date(s) of miscarriages: ___________________________________ |
Number of ectopic pregnancies: _____________ |
Date(s) of ectopic pregnancy: _______________________________ |
Number of abortions: _____________________ |
Date(s) of abortions_______________________________________ |
Number of stillbirths: _____________________ |
Date(s) of each stillbirth: ___________________________________ |
Number of children: ______________________ |
Are you Currently Breastfeeding? ____Yes |
____No |
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Length of time it took you or your partner to get pregnant. Shortest _____________ |
Longest ______________ |
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Pregnancy # |
Delivery |
Type of Delivery |
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Complications |
Weeks pregnant |
Height / |
Boy/Girl |
Date |
(Vaginal or C- |
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when delivered |
Weight |
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Section) |
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(prematurity) |
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1 |
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2. |
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3. |
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4. |
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Nation Wide Egg Donation Application 08/2011
Donation Application Form NWED DONOR NUMBER __________________________________ |
Page 8 |
Please note that the remaining portion of this application will be shared and viewed by recipients.
Please pay attention to the fact that the Intended Parents will be viewing your responses and your handwriting. Please make sure your writing is neat and legible.
Nation Wide Egg Donation Application 08/2011
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Donation Application Form NWED DONOR NUMBER __________________________________ |
Page 9 |
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PHYSICAL CHARACTERISTICS
THIS PAGE WILL BE SHARED AND VIEWED BY RECIPIENTS
Are you adopted? ____Yes ____No |
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Blood Type if known: ____________ |
Height: _______ Weight: ______ |
Date of Birth____________________ |
Recent weight loss/gain?____Yes ____No |
If yes _______lbs loss/gain (circle one) |
What was your weight at age 21? _______ |
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Please circle responses that best describe you below:
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Right Handed |
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Left Handed |
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Ambidextrous |
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Bone Structure: |
Small |
Medium |
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Large |
Very Large |
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Complexion: |
Very Fair Fair |
Light |
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Medium |
Olive Light Brown |
Dark Brown Ebony |
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Tan ability: |
None Slight |
Medium |
Easy |
Freckle |
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Skin Condition: |
Oily |
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Medium |
Dry Combination |
Dimples? ____Yes ____No |
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Eye Color: |
Blue |
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Brown |
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Lt. Brown |
Dark Brown |
Green |
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Hazel |
Eye set: Narrow |
Average |
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Wide |
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Eye Size: |
Small |
Average |
Large |
Shape: Round |
Oval Almond |
Natural Hair Color: |
Black |
Light Blonde |
Medium Blonde Dark Blonde |
Light Brown |
Medium Brown |
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Dark Brown |
Red |
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Hair Type: Curly |
Wavy |
Straight |
Hair Texture: |
Fine |
Medium |
Coarse |
Fullness: |
Thin |
Medium Thick |
Baldness: ____ Yes ____No |
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Baldness in Family: ____ Yes ____ No |
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Premature Graying: ____Yes ____No |
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If yes, at what age____ |
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Body and Facial Features: |
Small |
Medium |
Large |
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Condition of your teeth: Poor |
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Fair |
Good |
Excellent |
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Have you had any periodontal or orthodontic work? ____Yes |
____No If yes, at what age? _____ |
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Hearing (without corrective aids): |
Poor |
Fair |
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Good |
Excellent |
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Vision (without corrective lenses): |
Poor |
Fair |
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Good |
Excellent Prescription (If known): _________ |
Nation Wide Egg Donation Application 08/2011
Donation Application Form NWED DONOR NUMBER __________________________________ |
Page 10 |
PERSONAL HEALTH HISTORY
THIS PAGE WILL BE SHARED AND VIEWED BY RECIPIENTS
Do you wear glasses or contacts or have you had laser surgery? _____Yes _____No
If yes, are/were you: _____Nearsighted _____Farsighted ____Other (specify):____________
Do you have astigmatism (blurred vision due to an irregularity in the curvature of the cornea.? ____Yes ____No
If yes, age diagnosed ______. |
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Do you have any Allergies? |
_____Yes |
_____No |
If yes, are they to: ____Food(s)_____Medication(s) _____Environmental _____Latex
Please list any childhood allergies that you have outgrown: _________________________________
For each medication allergy, describe specific substance and reaction(s) and age first noticed:
Substance: ____________________ |
Reaction(s):_________________________ |
Age: _____ |
Substance: ____________________ |
Reaction(s):_________________________ |
Age: _____ |
Substance: ____________________ |
Reaction(s):_________________________ |
Age: _____ |
SOCIAL HISTORY AND HABITS
THIS PAGE WILL BE SHARED AND VIEWED BY RECIPIENTS
Religion Born Into: _____________________________ |
Religion Practiced:_____________________________ |
Grade Point Average (GPA): ___________ |
SAT Scores: Verbal _____ Math _____ |
ACT Score: _____ |
Education: |
_____ |
Did not Complete High School |
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Received GED |
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Completed high school |
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Currently in college, pursuing degree in _____________________________________________ |
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Completed college, degree in _________________________________ GPA:______________ |
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Currently pursuing an advanced degree in ___________________________________________ |
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Completed advanced degree in ____________________________________________________ |
Did you have any learning disabilities or weaknesses in school? If yes, describe: ________________________________
Academic Strengths (i.e. math, reading):________________________________________________________________
How many languages do you speak? _______________Which one (s): ________________________________________
Musical Talent or Instrument: _____________________________________________________Years Experience______
Nation Wide Egg Donation Application 08/2011
