Sperm Donor Jobs Details

On March 1st, 2018, the United States Cryobank (USCB) released an updated sperm donor application form. This new form is 8 pages long and covers a wide range of information about each donor. The goal of this new form is to provide potential parents with as much information as possible about each donor, in order to make an informed decision about who will be entrusted with creating their family. prospective sperm donors must complete this new form in order to become a USCB donor. The release of this new sperm donor application form comes at a time when the demand for donated sperm is growing rapidly.

This table includes information regarding sperm donor application. It's really worth spending some time to study this before starting filling in your document.

QuestionAnswer
Form NameSperm Donor Application
Form Length27 pages
Fillable?No
Fillable fields0
Avg. time to fill out6 min 45 sec
Other namessperm donation registration, sperm donation form, sperm donor register, sperm job for apply

Form Preview Example

 

Donation Application Form NWED DONOR NUMBER __________________________________

Page 1

 

 

 

 

 

 

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.

 

 

 

NAME AS IT APPEARS ON YOUR DRIVER’S LICENSE

 

Last name: __________________________

First name: ___________________ Middle Initial: _____

 

Sex: Male ______ Female ______

Age: _______

 

Date of Birth: ____/____/____ Place of Birth:_________________

 

Soc. Security #: ______-______-________

Are you a US citizen or permanent resident? Yes

No

Driver’s License #:______________________

State:__________

 

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 __________________________________

Page 2

DEMOGRAPHICS

MAILING ADDRESS:

Street: __________________________________________________City: ______________________________

State/Province: ____________ Zip/ Postal code: _______________ Country: ______________

 

 

 

OK to leave message?

Home Phone Number:

(

) _______- ________

Yes

No

Work Phone Number:

(

) _______- ________

Yes

No

Cell Phone Number:

(

) _______- ________

Yes

No

Email Address:

__________________________________________________

Do you have medical insurance? ____Yes

____No

 

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)____________________

 

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

 

Donation Application Form NWED DONOR NUMBER __________________________________

Page 3

 

 

 

 

 

 

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:

 

 

 

 

 

 

 

 

 

Jobs/Duties

Year Began

Year End

 

 

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

 

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:

 

Response

When?

How Often?

Toxic Chemicals or Substances

 

Yes

No

 

 

Sprays

 

Yes

No

 

 

Fumes/Exhaust

 

Yes

No

 

 

Radiation

 

Yes

No

 

 

Flea Powder/Sprays

 

Yes

No

 

 

Lead/Lead products

 

Yes

No

 

 

Asbestos/Asbestos products

 

Yes

No

 

 

Pesticides/Herbicides

 

Yes

No

 

 

Cleaning solutions/solvents

 

Yes

No

 

 

 

 

 

 

 

 

Nation Wide Egg Donation Application 08/2011

 

Donation Application Form NWED DONOR NUMBER __________________________________

Page 5

 

 

 

 

 

 

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

 

 

If yes, how many cigarettes per day? __________

 

 

If no, what year/month did you stop? __________

 

 

How many years did you smoke? _____

 

 

What best describes your alcohol consumption? ____Never drink

 

 

____ 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

 

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

 

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?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

Donation Application Form NWED DONOR NUMBER __________________________________

Page 6

 

 

 

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

 

CONTRACEPTIVE HISTORY:

 

 

 

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? ___________________________

 

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

 

Donation Application Form NWED DONOR NUMBER __________________________________

Page 7

 

 

 

 

 

 

 

 

 

 

 

MENSTRUAL AND REPRODUCTIVE HISTORY: FOR EGG DONORS

 

 

 

 

 

 

 

 

 

 

 

 

 

Age at onset of menses: _______

 

Date of Last Menstrual Period: ____________

 

Are your menstrual periods regular: _____Yes

_____No

 

 

 

 

How long is your monthly cycle (first day of one period to first day of the next)? ________days

 

 

 

Are you periods regular when you are not on any type of hormonal birth control such as the pill, etc.? ____Yes

____ No

 

If no, how many times per year do you menstruate? ___________

 

 

 

How many days does your period usually last? ______ days

 

 

 

 

Do you bleed or spot between periods? _____Yes _____No

 

 

 

Do you get menstrual cramps before, during, or after your period? ____Yes ____No

 

 

 

If yes, are your cramps: mild

moderate

severe?

 

 

 

If yes, do you use medication alleviate the pain? _____Yes

_____No

 

 

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:

 

 

 

 

 

 

Number of pregnancies:___________________

 

 

 

 

 

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

 

Length of time it took you or your partner to get pregnant. Shortest _____________

Longest ______________

 

 

 

 

 

 

 

Pregnancy #

Delivery

Type of Delivery

 

Complications

Weeks pregnant

Height /

Boy/Girl

Date

(Vaginal or C-

 

 

when delivered

Weight

 

 

Section)

 

 

(prematurity)

 

1

 

 

 

 

 

 

 

2.

 

 

 

 

 

 

 

3.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4.

 

 

 

 

 

 

 

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

 

 

Donation Application Form NWED DONOR NUMBER __________________________________

Page 9

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PHYSICAL CHARACTERISTICS

THIS PAGE WILL BE SHARED AND VIEWED BY RECIPIENTS

Are you adopted? ____Yes ____No

 

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? _______

 

Please circle responses that best describe you below:

Right Handed

 

Left Handed

 

Ambidextrous

 

 

 

 

Bone Structure:

Small

Medium

 

Large

Very Large

 

 

 

 

Complexion:

Very Fair Fair

Light

 

Medium

Olive Light Brown

Dark Brown Ebony

 

 

Tan ability:

None Slight

Medium

Easy

Freckle

 

 

 

 

 

Skin Condition:

Oily

 

Medium

Dry Combination

Dimples? ____Yes ____No

 

Eye Color:

Blue

 

Brown

 

Lt. Brown

Dark Brown

Green

 

Hazel

Eye set: Narrow

Average

 

Wide

 

Eye Size:

Small

Average

Large

Shape: Round

Oval Almond

Natural Hair Color:

Black

Light Blonde

Medium Blonde Dark Blonde

Light Brown

Medium Brown

 

 

Dark Brown

Red

 

 

 

 

 

 

 

Hair Type: Curly

Wavy

Straight

Hair Texture:

Fine

Medium

Coarse

Fullness:

Thin

Medium Thick

Baldness: ____ Yes ____No

 

Baldness in Family: ____ Yes ____ No

 

 

 

Premature Graying: ____Yes ____No

 

If yes, at what age____

 

 

 

 

Body and Facial Features:

Small

Medium

Large

 

 

 

 

 

Condition of your teeth: Poor

 

Fair

Good

Excellent

 

 

 

 

Have you had any periodontal or orthodontic work? ____Yes

____No If yes, at what age? _____

 

Hearing (without corrective aids):

Poor

Fair

 

Good

Excellent

 

 

 

Vision (without corrective lenses):

Poor

Fair

 

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 ______.

 

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

 

 

 

_____

Received GED

 

 

 

 

_____

Completed high school

 

 

 

 

_____

Currently in college, pursuing degree in _____________________________________________

 

_____

Completed college, degree in _________________________________ GPA:______________

 

_____

Currently pursuing an advanced degree in ___________________________________________

 

_____

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

Donation Application Form NWED DONOR NUMBER __________________________________

Page 11

SOCIAL HISTORY AND HABITS (continued)

THIS PAGE WILL BE SHARED AND VIEWED BY RECIPIENTS

Artistic Talent: _____________________________________________________________________________________

Athletic Skills / Favorite Sports: _______________________________________________________________________

Other skills/hobbies/talents/interests do you have (i.e. writing, reading, ability to do games or crossword puzzles, handcrafts)? Describe: _____________________________________________________________________________

Current Occupation: ________________________________ How long have you been at your current job? __________

HABITS:

 

Exercise Habits: _____None _____Occasional _____Regular

Type of Exercise: ______________________________

Your diet is: ____Vegetarian ____Non-vegetarian

Your diet is: poor average excellent

Do you have any dietary restrictions? _________________________________________________________________

REPRODUCTIVE HISTORY

THIS PAGE WILL BE SHARED AND VIEWED BY RECIPIENTS

YOUR CHILDREN

1

2

3

4

Age

Sex

Eye color

Hair Color

Frame size

Grade in school

Personality

Artistic ability

Intelligence

Distinguishing characteristics

Wears eye glasses

Discipline problems

Any medication

Dyslexia

Reading difficulties

Speech difficulties

Any special services at school

Seen by Social worker/ psychiatrist

Grade functional level:

Normal / Above/ Below Average

Nation Wide Egg Donation Application 08/2011

 

 

Donation Application Form NWED DONOR NUMBER __________________________________

Page 12

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FAMILY HEALTH HISTORY

THIS PAGE WILL BE SHARED AND VIEWED BY RECIPIENTS

How many blood siblings are in your immediate family (including yourself and half siblings)? _________

Number of Brothers __________

Number of Sisters __________

Number of Maternal Aunts ___________

Number of Maternal Uncles ___________

Number of Paternal Aunts ___________

Number of Paternal Uncles ___________

Do you have any brothers or sisters that died in infancy or childhood? _____Yes _____No

If yes, what was the cause? ____________________________________________________________________

Are there any members of your family with a history of learning disabilities or autism? _____Yes _____No

If yes, please explain ______________________________________________________________________

Describe genetic family members according to the following characteristics. Use natural eye and hair color; fair/dark, etc. complexion. If they are deceased, please list cause of death. Please do not put “natural” as a cause of death. If unknown, write “unknown.”

Eye Hair Complexion Color Color

Height

Weight

Bone

Occupation/

 

 

Structure

Education

 

 

 

Age if

living

Age at time

of death

Cause of

death

Sister(s)

Brother(s)

Mother

Father

Maternal

Grandmother

Materanl

Grandfather

Paternal

Grandmother

Paternal

Grandfather

Nation Wide Egg Donation Application 08/2011

 

Donation Application Form NWED DONOR NUMBER __________________________________

Page 13

 

 

 

 

 

 

FAMILY HEALTH HISTORY (continued)

THIS PAGE WILL BE SHARED AND VIEWED BY RECIPIENTS

Carefully review the following list of medical problems and identify which ones you or one of your genetic relatives have or had. Please consider each condition carefully for each family member. Explain any conditions you check below, indicating which side of the family (maternal or paternal), the age at the time of onset, and any other pertinent information. If you and none of your indicated family members have a history of the specific medical condition, please indicate none.

*PLEASE REFER TO THE GLOSSARY ON THE LAST PAGES OF THIS FORM FOR DEFINITIONS

None

 

Self

 

 

Mother

 

Father

 

Sibling

Grand-

 

Aunt/

 

 

Cousin

 

Explanation (which side of family,

 

 

 

 

 

 

 

 

 

 

parents

 

Uncle

 

 

 

 

age of onset, etc.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CANCER

Breast

Colon or Intestinal

Lung

Ovarian or Uterine

Prostate or Testicular

Skin

Stomach

Thyroid

Blood (e.g. leukemia)

Other

HEART

Stroke

Heart Attack

Congenital Heart

Disease

Heart Disease or

Defect

Hardening of the

Arteries

High Blood Pressure

High cholesterol level

Nation Wide Egg Donation Application 08/2011

 

Donation Application Form NWED DONOR NUMBER __________________________________

Page 14

 

 

 

FAMILY HEALTH HISTORY (continued)

THIS PAGE WILL BE SHARED AND VIEWED BY RECIPIENTS

None

 

Self

 

Mother

 

Father

 

Sibling

Grand-

 

Aunt/

 

Cousin

 

Explanation (which side of family,

 

 

 

 

 

 

 

 

 

parents

 

Uncle

 

 

 

age of onset, etc.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

BLOOD

Anemia

Sickle-Cell Anemia

Factor V Leiden thrombpphilia (Blood clots or strokes)

Hemophilia or other

Bleeding/Clotting

Disorders such as

Von Willebrand’s

Disease

Immune Deficiency

Leukemia

Lymphoma or

Swollen Lymph

Nodes

HIV

Thalassemia

Polyarteritis Nodosa

Other Blood Disorder

RESPIRATORY

Asthma

Hay Fever

Emphysema

Tuberculosis

Pneumonia

Alpha-1 antitrypsin

Disorder

Blood in Sputum

Other Lung Disease

Nation Wide Egg Donation Application 08/2011

 

Donation Application Form NWED DONOR NUMBER __________________________________

Page 15

 

 

 

 

 

 

FAMILY HEALTH HISTORY (continued)

THIS PAGE WILL BE SHARED AND VIEWED BY RECIPIENTS

None

Self

Mother

Father

Sibling

Grand-

Aunt/

Cousin

Explanation (which side of family,

 

 

 

 

 

parents

Uncle

 

age of onset, etc.)

GASTRO-

INTESTINAL

Appendicitis

Ulcer of Stomach or

Duodenum

Gallstones

Hepatitis A,B or C

Cirrhosis of the Liver

Other Liver Disease

Ulcerative Colitis

Crohns Disease

Pyloric Stenosis

Multiple Polyps of the

Colon

Rectal Disorder

Inflammatory Bowel

Disease

Any other problem of the digestive system

METABOLIC/

ENDOCRINE

Diabetes requiring insulin therapy

Diabetes not requiring insulin therapy

Childhood Diabetes

Thyroid disorder

Goiter

Hypoglycemia

Adrenal Dysfunction or Disorder

Phenyl Ketonuria (PKU) or inherited Metabolism Disorder

Obesity

Dwarfism

Nation Wide Egg Donation Application 08/2011

 

 

Donation Application Form NWED DONOR NUMBER __________________________________

Page 16

 

 

 

 

 

 

 

 

 

 

FAMILY HEALTH HISTORY (continued)

THIS PAGE WILL BE SHARED AND VIEWED BY RECIPIENTS

None

Self

Mother

Father

Sibling

Grand-

Aunt/

Cousin

Explanation (which side of family,

 

 

 

 

 

parents

Uncle

 

age of onset, etc.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

URINARY

Kidney Problems

Polycystic Kidney

Disease

Other disease/ defect of urinary tract (urethra, bladder, ureter)

GENITAL/

REPRODUCTIVE

Hermaphroditism/

Ambiguous Genitals

Hypospadias or undescended testicle

Uterine Fibroids

Ovarian Cysts or

Ruptured

Lumps or Cysts in

Breast or Discharge

Polycystic Ovarian

Syndrome (PCOS)

Pelvic Inflammatory

Disease (PID)

Endometriosis

REPRODUCTIVE

OUTCOMES

2 or more Miscarriages

Stillborn

Premature

Menopause

Death of a newborn infant

Childhood death

Birth defects

Infertility

Premature Birth

Nation Wide Egg Donation Application 08/2011

 

 

Donation Application Form NWED DONOR NUMBER __________________________________

Page 17

 

 

 

 

 

 

 

 

 

 

FAMILY HEALTH HISTORY (continued)

THIS PAGE WILL BE SHARED AND VIEWED BY RECIPIENTS

None

Self

Mother

Father

Sibling

Grand-

Aunt/

Cousin

Explanation (which side of family,

 

 

 

 

 

parents

Uncle

 

age of onset, etc.)

NEUROLOGICAL

Migraines

Mental retardation

Senility or Mental Deterioration before age 50

Multiple Sclerosis

Cerebral Palsy

Neurofibromatosis

Epilepsy / Seizures

Attention Deficit

Disorder/

Hyperactivity

Autism / Asperger’s

Alzheimer’s

Disease/Dementia

Hydrocephalus

Tuberous Sclerosis

Parkinson’s Disease

Creutzfeldt-Jakob

Disease

Scoliosis

Myasthenia Gravis

Huntington’s or

Wilson’s Disease

Tourette’s syndrome

Other diseases of the nervous system

MENTAL

HEALTH

Anxiety / Panic

Attacks

Anorexia / Bulemia/other eating disorders

Nation Wide Egg Donation Application 08/2011

Donation Application Form NWED DONOR NUMBER __________________________________

Page 18

 

 

FAMILY HEALTH HISTORY (continued)

THIS PAGE WILL BE SHARED AND VIEWED BY RECIPIENTS

None

Self

Mother

Father

Sibling

Grand-

Aunt/

Cousin

Explanation (which side of family,

 

 

 

 

 

parents

Uncle

 

age of onset, etc.)

Depression

Schizophrenia

Manic Depressive or

Bipolar Disorder

Other mental health disorder requiring hospitalization

Suicide Attempts

Other mental health problems that warranted counseling (please list)

MUSCLE/BONE/

JOINTS

Muscular Dystrophy

Achondroplasia form of dwarfism with abnormal bone growth

Other Chronic

Muscle Disease

Osteogenesis imperfecta (brittle bone disease)

Loss of Muscle

Coordination

Osteoporosis

Marfan Syndrome

Arthritis

Rheumatoid or

Juvenile Arthritis

Spinal Muscular

Atrophy

Hereditary Low Back Disorder or Deformity of Spine

Reiter’s Disease

Myasthenia Gravis

Gout

Nation Wide Egg Donation Application 08/2011

 

Donation Application Form NWED DONOR NUMBER __________________________________

Page 19

 

 

 

 

 

 

FAMILY HEALTH HISTORY (continued)

THIS PAGE WILL BE SHARED AND VIEWED BY RECIPIENTS

None

Self

Mother

Father

Sibling

Grand-

Aunt/

Cousin

Explanation (which side of family,

 

 

 

 

 

parents

Uncle

 

age of onset, etc.)

Metabolic Bone Disease (be more specific)

Lupus (systemic lupus erythematosis

SLE)

SIGHT/SOUND/

SMELL

Deafness before age 60

Deformity of the ear

Cataracts before age 50

Blindness

Color Blindness

Severe Myopia

Glaucoma

Retinoblastoma

Retinitis Pigmentosa

Deviated Septum

Any other Sensory

Disorder

SKIN

Acne

Albinism

Eczema

Excessive Facial

Hair (Hirsutism)

Pigmentation

Disorders

Psoriasis

Neurofibromatosis

Nation Wide Egg Donation Application 08/2011

 

 

Donation Application Form NWED DONOR NUMBER __________________________________

Page 20

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FAMILY HEALTH HISTORY (continued)

THIS PAGE WILL BE SHARED AND VIEWED BY RECIPIENTS

None

Self

Mother

Father

Sibling

Grand-

Aunt/

Cousin

Explanation (which side of family,

 

 

 

 

 

parents

Uncle

 

age of onset, etc.)

Other disorders of the skin

Infectious Skin

Disease

More than 5 purple- or coffee- colored spots on skin (size of quarter or larger)

CONGENITAL

ABNORMALITIES/

BIRTH DEFECTS

Cleft Lip / Palate

Congenital Hip

Problems

Club Feet

Heart Defect

Hearing Problems

Spina Bifida -Neural

Tube (open spine)

Microcephaly

Holoprosencehpaly

asingle-lobed brain structure and severe skull and facial defects

Other

CHROMOSOMAL

ABNORMALITIES

Down Syndrome

Other (i.e. Turner,

Fragile X,

Klinefelter’s etc.)

OTHER

Alcoholism

Drug abuse, Misuse or Addiction

Premature degeneration of any organ system

Any other condition not mentioned above

Explain: __________________________________________________________________________________________

_________________________________________________________________________________________________

Nation Wide Egg Donation Application 08/2011

 

 

Donation Application Form NWED DONOR NUMBER __________________________________

Page 21

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

GENETIC HISTORY

THIS PAGE WILL BE SHARED AND VIEWED BY RECIPIENTS

Ethnic origin (e.g., French, Irish)

Mother: _____________________________________ Father: __________________________________________

Race: Check all that apply for your ancestors:

 

African American

___Mother___Father___MGM___MGF___PGM___PGF

Eastern European (Ashkenazi) Jewish

___Mother___Father___MGM___MGF___PGM___PGF

Mediterranean (Greek, Italian)

___Mother___Father___MGM___MGF___PGM___PGF

Hispanic

___Mother___Father___MGM___MGF___PGM___PGF

Indian (from India)

___Mother___Father___MGM___MGF___PGM___PGF

Southeast Asian (Laotian, Vietnamese, Cambodian)

___Mother___Father___MGM___MGF___PGM___PGF

French Canadian

___Mother___Father___MGM___MGF___PGM___PGF

Cajun

___Mother___Father___MGM___MGF___PGM___PGF

(MGM=Maternal Grandmother, MGF=Maternal Grandfather; PGM=Paternal Grandmother, PGF=Paternal Grandfather)

Have you or anyone in your family ever been tested positive as a carrier or had any of any of the following diseases?

Blooms Syndrome

No

If yes:

_____ disease_____carrier _____negative

_____unknown

Canavan

No

If yes:

_____ disease

_____carrier

_____negative

_____unknown

Cystic Fibrosis

No

If yes:

_____ disease

_____carrier

_____negative

_____unknown

Fabry Disease

No

If yes:

_____ disease

_____carrier

_____negative

_____unknown

Familial Dysautonomia

No

If yes:

_____ disease

_____carrier

_____negative

_____unknown

Familial Mediterranean Fever

No

If yes:

_____ disease

_____carrier

_____negative

_____unknown

Fanconi Anemia Grp. C:

No

If yes:

_____ disease

_____carrier

_____negative

_____unknown

Gaucher

No

If yes:

_____ disease

_____carrier

_____negative

_____unknown

Niemann-Pick type A

No

If yes:

_____ disease

_____carrier

_____negative

_____unknown

Mucolipidosis type IV

No

If yes:

_____ disease

_____carrier

_____negative

_____unknown

Sickle Cell

No

If yes:

_____ disease

_____carrier

_____negative

_____unknown

Tay-Sachs

No

If yes:

_____ disease

_____carrier

_____negative

_____unknown

Thalassemia

No

If yes:

_____ disease

_____carrier

_____negative

_____unknown

Is there anything else we should know about your family?

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

Nation Wide Egg Donation Application 08/2011

 

 

Donation Application Form NWED DONOR NUMBER __________________________________

Page 22

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PERSONAL AND MOTIVATIONAL

THIS PAGE WILL BE SHARED AND VIEWED BY RECIPIENTS

In your own words, describe your personality, temperament, and

character:________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

What physical, artistic, intellectual or social abilities do you feel best about:

________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

What are your present and future career goals:___________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

What are your present and future personal goals: ________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

List the 3 achievements you are most proud of:

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

Nation Wide Egg Donation Application 08/2011

 

 

Donation Application Form NWED DONOR NUMBER __________________________________

Page 23

 

 

 

 

 

 

 

 

 

 

PERSONAL AND MOTIVATIONAL (continued)

THIS PAGE WILL BE SHARED AND VIEWED BY RECIPIENTS

What is your favorite movie? _________________________________________________________________________

What is your favorite book? __________________________________________________________________________

What is your favorite color? __________________________________________________________________________

What is your favorite food? __________________________________________________________________________

What is one of your most memorable moments and why?

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

If you could change one thing about yourself, what would it be and why?

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

Is there a person alive or dead whom you admire and why?

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

What would you do on a “perfect” day if you could do anything you wanted?

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

Describe your personality and temperament as a child:

_______________________________________________________________________________________________________ _____

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

What was your favorite thing to do as a child?

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

Nation Wide Egg Donation Application 08/2011

 

 

Donation Application Form NWED DONOR NUMBER __________________________________

Page 24

 

 

 

 

 

 

 

 

 

 

PERSONAL AND MOTIVATIONAL (continued)

THIS PAGE WILL BE SHARED AND VIEWED BY RECIPIENTS

What did your parents teach you to value?

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

How were you in comparison to other children?

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

Describe your personality and temperament as a teenager:

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

Did you have any problems as a child and/ or as a teenager? Explain:

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

Who was the most important influence on you and why?

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

What were your ambitions/ goals as a teenager?

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

What were your best and worst subjects in school?

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

Nation Wide Egg Donation Application 08/2011

Donation Application Form NWED DONOR NUMBER __________________________________

Page 25

PERSONAL AND MOTIVATIONAL (continued)

THIS PAGE WILL BE SHARED AND VIEWED BY RECIPIENTS

Please provide the following information about your family:

Intellectual/Academic Achievements

Artistic Achievements

Mother

 

Father

 

Sisters

 

Brothers

Reasons for wanting to donate eggs or sperm : _______________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

If you could pass on a message to the recipient(s) of your eggs or sperm, what would that message be?

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

If you could write a message to the child born through your participation as an egg or sperm donor for when he/she turns 18 years old, what would you tell him/her?

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

Nation Wide Egg Donation Application 08/2011

Donation Application Form NWED DONOR NUMBER __________________________________

Page 26

Please attach several photographs of yourself (Ages 1 – 8 years, no adult photos please).

THIS PAGE WILL BE SHARED AND VIEWED BY RECIPIENTS

Email to Tiffany or Kristine

Tiffany_NWED@Yahoo.com

Or

Kristine_NWED@Yahoo.com

Upon receiving your application, one of the coordinator’s above will contact you to go through the entire process with you so that you understand the process and feel comfortable continuing as a donor with this agency.

You have a responsibility to contact this agency if anything in your health history changes that would

be important for a clinic and/or family to know of.

Thank you for taking the time to fill out this application. We look forward to working with you.

NATION WIDE EGG DONATION

Nation Wide Egg Donation Application 08/2011

Donation Application Form NWED DONOR NUMBER __________________________________

Page 27

If you have been a donor before please fax this form back with your application

Nation Wide Egg Donation

P.O. Box 533, Meridian, ID 83680-0533 (208)895-8667 Fax (208) 895-8072 www.NationWideEggDonation.com

Consent for Release of Information

(X ) To obtain information from

(X ) To release information to

(X ) To communicate with

____________________________________________________________________

Individuals Name:Date of Birth:

____________________________________________________________________

Address:

____________________________________________________________________

Please list name, address and phone number of clinic/s where you have donated

Regarding : Previous Egg Donation Cycles Medical Records, Stem Sheets, Cystic Fibrosis Results, Retrieval Reports and any Psychological Evaluation Reports

The purpose or need for the above shall be: To obtain copies of all medical records pertaining to the above for said individual signing this release.

This authorization is limited to the Recipient Couples, Nation Wide Egg Donation (or a sister agency to NWED), Medical clinics and doctors upon request.

I hereby authorize the release of the above information from my record/s. I understand that the information to be released from my record/s is confidential and protected from disclosure. I also understand that my consent for release of Information will expire 1 year from this date if not acted upon prior to that time. A copy of this medical release may be used in lieu of an original.

________________________________ ____________________________

SignatureDate

________________________________

Name Printed

Nation Wide Egg Donation Application 08/2011