deb usa egg donor application
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8/10/2019 DEB USA Egg Donor Application
1/17
"#$#% &'() **************
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Thank you for applying to be a donor with Donor Egg Bank USA. We are appreciative of your willingness to participate inour program to help women and men who are unable to conceive. It is very important that we learn as much as possibleabout your personal and extended family medical history. This information is important to help us ensure you remain agood candidate for egg donation as well as it gives our patients insight into your background to help them choose the bestdonor for their family building purpose.
Please provide complete and accurate information to the following questions. If you have donated in the past, pleaserequest a copy of your application so you may utilize it when filling out the family history portions. It will save you time andhelp you remember accurately your family history without needing to consult family members again. As well, pleaseupdate any area of the application that may have changed since your last donation cycle. Any information you provideduring the donation process, will remain completely confidential. Some of the information from this questionnaire will begiven to the recipient(s), after all identifying information is removed. Prospective recipients will view your profile as well asany baby, childhood or adult photos you provide.
Instructions:
1. Please fill in all blanks completely. Please complete all questions.
a. Incomplete applications will not be accepted or returned.
b. Please keep in mind that the information you provide will be viewed by potential recipients and do not
provide identifying information such as jobs, schools, names of relatives, etc.
c. Please write legible and provide as much detail as possible. We will not correct grammatical mistakes
when uploading your profile to our database.
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 sister or brother, or maternal cousin, paternal grandfather (PGF).
a. A Yes response will not necessarily eliminate you as a potential donor. Most people will have at
least one or more of these conditions in themselves or a family member. The accuracy of the
information you will be providing will impact potential families you may help create.
3. Please provide information on all the relatives requested. Do not write their names.
a. If your grandparents were deceased prior to your birth, please ask a family member for their (your
grandparents) physical characteristics, cause of death and medical history. Do not write NA.
4. Please remember the donation is anonymous, therefore we ask that you do not list towns or potential
identifying information.
5. Please be sure to include at least 3 adult photographs of you aloneand 3 childhood photographs, potential
recipients love to see pictures!
6. Before entering your height and weight, please weigh and measure yourself. It is important that this is
accurate and not an estimate.
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8/10/2019 DEB USA Egg Donor Application
2/17
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Date application was completed: ___________________
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Name
Street Address
City, State, Zip Code
Home Phone OK to leave Message? Yes No
Work Phone OK to leave Message? Yes No
E-Mail Address
Last 4 digits of
Social Security Number
Date of Birth Place of Birth
Partners Name Phone
Emergency Contact Name Phone
Fertility Center where
treatment will occur?
'/01)*&( */&$&*+-$)1+)*1
Please circle the race below that best describes you:
Caucasian African American Hispanic Asian Middle Eastern Pacific Islander Multi-Racial
What is your ancestors ethnic background or countries of origin? (French, German, Native American etc.):
__________________________________________________________________________________________
Are you of Jewish heritage or was your mother Jewish? Yes No
Age: ___________ Height: _____________ Weight (lbs.): ______________
Body Frame: Small Medium Large Dress Size: ____________ Shoe Size: ___________
Complexion: Very Fair Fair Light Medium Olive Light Brown Dark Brown Ebony
Eye Color: Blue Brown Grey Hazel Green
Blood Type: _____________
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8/10/2019 DEB USA Egg Donor Application
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"#$#% &'() ***************
Hair (Check All That Apply):
Curly/wavy (Naturally) Straight (Naturally) Average Texture Thin Texture Thick Texture
Premature Graying (What Age: ______)
Natural Hair Color (Now): _________________ Hair Color as a Child: _________________
Are you: Right Handed Left Handed Ambidextrous
Are you adopted? Yes No
Marital Status: Single Married Divorced Separated Widowed Partnered (same-sex only)
Religion: _________________________
-!2*&+)"#
Select the highest level of education achieved:
GED
High School
Trade School (Type of Trade School: ___________________________________)
Some College
Associates Degree (Major: __________________________________________)
Bachelors Degree (Major: __________________________________________)
Some Graduate School (Major: __________________________________________)
Masters Degree (Major: __________________________________________)
Doctorate Degree (Major: __________________________________________)
Medical Degree
Law Degree
Do you have any additional educational goals? __________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
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8/10/2019 DEB USA Egg Donor Application
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List jobs held in the past five years:*Please do not include name of employer/company - only job title*
Jobs/Duties Year Began Year End
14)((1 ! &5)()+)-1
What languages do you speak, read, or write? ____________________________________________________________
What were your academic strengths (i.e. Math, English, Science)? ____________________________________________
Athletic skills and/or favorite sports? ____________________________________________________________________
Have you done any volunteer work? If yes, please explain: __________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Do you play any instruments? If yes, what do you play? ____________________________________________________
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8/10/2019 DEB USA Egg Donor Application
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"#$#% &'() ***************
Please rate your aptitudes on the following abilities (1 = Poor, 5 = Excellent):
Mathematical Ability: 1 2 3 4 5
Scientific Ability: 1 2 3 4 5
Athletic Ability: 1 2 3 4 5
Singing Ability: 1 2 3 4 5
Artistic Ability: 1 2 3 4 5
Additional Comments: _______________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
'-$1"#&( .-!)*&( ! 1"*)&( /)1+"$0
Vision (Without Corrective Lenses): Poor Fair Good Excellent
Do you wear corrective lenses? Yes No
If yes, for what problem(s)? Nearsighted Farsighted Other (explain): ______________________________
Have you had corrective eye surgery? Yes No
If yes, for what problem(s)? Nearsighted Farsighted Other (explain): ______________________________
Hearing (Without Corrective Aids): Poor Fair Good Excellent
Do you wear hearing aids? Yes No If yes, for what problem(s)? ________________________________
Condition of Teeth: Poor Fair Good Excellent
Have you ever had Dental Braces? Yes No
Do you smoke cigarettes? Yes No If yes, how many cigarettes per day? _____________________
Do you drink alcohol? Yes No If yes, how often? ____________________________________
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8/10/2019 DEB USA Egg Donor Application
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"#$#% &'() ***************
Diet: Vegetarian Non-Vegetarian
Diet (Nutrition): Poor Average Good
Allergies: Yes No
If yes, are they to: Food(s) Medication(s) Environmental
For each allergy, describe specific substance and reaction(s) and age first noticed:
Substance: __________________________ Reaction(s): _______________________________ Age: _______
Substance: __________________________ Reaction(s): _______________________________ Age: _______
Substance: __________________________ Reaction(s): _______________________________ Age: _______
Substance: __________________________ Reaction(s): _______________________________ Age: _______
Explain allergies you have outgrown: ___________________________________________________________________
_________________________________________________________________________________________________
Exercise: None Occasional Regular
Type of Exercise: __________________________________________________________________________________
Have you had any surgery (ies): Yes No
If yes, please explain: ______________________________________________________________________________
Have you had any hospitalization(s) not mentioned above? Yes No
If yes, please explain: ______________________________________________________________________________
If yes, have you ever been hospitalized for psychiatric care? Yes No
Have you ever been convicted of a crime? Yes No
If yes, for what reason? _____________________________________________________________________________
Did you spend any time in jail? Yes No
If yes, for what length of time? __________________
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8/10/2019 DEB USA Egg Donor Application
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"#$#% &'() ***************
60#-*"("60 ! ,-$+)()+0 /)1+"$0
Age menstrual periods began: ______________________________________
How many days does your period usually last? _________________________
Number of pregnancies: ____________________ Dates of pregnancies: ______________________________
Number of miscarriages: ___________________ Dates of miscarriages: _____________________________
Number of abortions: ______________________ Dates of abortions: ________________________________
Number of stillbirths: ______________________ Dates of each stillbirth: _____________________________
Number of children: _______________________ Are you Currently Breastfeeding? _____________________
Pregnancy #
Male / Female Delivery Date Complications Length / Weight
1
2.
3.
4.
5.
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8/10/2019 DEB USA Egg Donor Application
8/17
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"#$#% &'() ***************
Child 1 2 3 4 5
Age
Sex
Eye Color
Hair Color
Frame Size
Age Walked
Age Talked
Age Toilet Trained
Grade Level in School
Wears Eye Glasses
Wears Braces
Hyperactive, ADD, ADHD
Discipline Problems
Any Medication
Attention Deficits
Emotional Problems
Dyslexia
Reading Difficulties
Speech Difficulties
Eye/Hand Motor Coordination
Any Special Services at School
Seen by Social Worker/Psychiatrist
Grade Function Average:
Normal / Above / Below
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8/10/2019 DEB USA Egg Donor Application
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Describe biological family members according to the following characteristics:
Use natural eye and hair color. Use fair, dark, olive etc. for complexion. Use small, medium, large for body frame
Age
if
Living
Age at
Death
Cause of
Death
Eye
Color
Hair
Color Complexion Height Weight
Body
Frame Ancestry
Mother
Father
MaternalGrandmother
MaternalGrandfather
PaternalGrandmother
PaternalGrandfather
Full Sibling
__M __F
Full Sibling
__M __F
Full Sibling
__M __F
Full Sibling
__M __F
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8/10/2019 DEB USA Egg Donor Application
10/17
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"#$#% &'() ***************
Has anyone in your family, including yourself, experienced recurring and/or chronic symptoms that have not been
evaluated by a physician? (Please include those symptoms that you may not consider serious)
Yes No
If yes, please explain: _______________________________________________________________________________
_________________________________________________________________________________________________
Does anyone in your family, including yourself, experience baldness?
Yes No
If yes, who? ________________________________________ What age(s) did they start balding? ________________
Are there any known genetic diseases or conditions that run in your family?
Yes No
If yes, please identify: _______________________________________________________________________________
Have you or any family members described above had genetic counseling?
Yes No
If yes, please describe: ______________________________________________________________________________
Are there any members of your family, including yourself and children, with a history of learning disabilities?
Yes No
If yes, please explain: _______________________________________________________________________________
_________________________________________________________________________________________________
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8/10/2019 DEB USA Egg Donor Application
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"#$#% &'() ***************
Carefully review the following list of medical problems and identify any which are present in biological family members.
Please specify specific family members (e.g. Maternal Grandmother, Paternal Aunt etc.) and age of diagnosis if known.
*Please include only conditions diagnosed by a medical provider, not presumed diagnosis.*
You Child Mother Father Brother SisterGrand-parent
Aunt/Uncle
1stCousin Comments
Circulation
(check here if no to all )
Stroke
Heart Attack
Congestive Heart Failure
High Blood Pressure
High Cholesterol
Congenital Heart Disease
Heart Disease
Blood
(check here if no to all )
Anemia
Hemophilia or otherbleeding disorder
HIV/AIDS
Leukemia
Other Blood Disorder
Respiratory/Lungs
(check here if no to all )
Asthma
Emphysema
Tuberculosis
Gastrointestinal
(check here if no to all )
Ulcer of Stomach/Duodenum
Ulcerative Colitis
Hepatitis - A,B or C
Crohn's Disease
Inflammatory Bowel Disease
Any other cancer/problemwith digestive system
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8/10/2019 DEB USA Egg Donor Application
12/17
3+
"#$#% &'() ***************
You Child Mother Father Brother SisterGrand-parent
Aunt/Uncle
1st
Cousin Comments
Metabolic/Endocrine
(check here if no to all )
Diabetes
(Requiring Insulin)
Diabetes(Not Requiring Insulin)
Thyroid Disease(Hypo/Hyper)
Adrenal Gland Disorder
PKU or InheritedMetabolism Disorder
Dwarfism
Urinary
(check here if no to all )
Kidney DiseaseOther disease/defectof urinary tract
(urethra, bladder, ureter)
Genital/Reproductive
(check here if no to all )
Infertility
Miscarriage or Stillborn
Uterine Fibroids
Endometriosis
Ovarian Cysts
Other Genitalor Reproductive Diseases
Nervous System
(check here if no to all )
Migraine Headaches
Mental retardation
Senility before age 50
Multiple Sclerosis
Cerebral Palsy
Epilepsy/Seizure
Spina Bifida(Neural Tube Defect)
Parkinson's Disease
Alzheimers Disease
Huntington's Disease
Brain Tumor
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8/10/2019 DEB USA Egg Donor Application
13/17
3,
"#$#% &'() ***************
You Child Mother Father Brother SisterGrand-parent
Aunt/Uncle
1st
Cousin Comments
Mental Healthor Learning Disability
(check here if no to all )
Depression (Current or Past)
Schizophrenia
Manic Depressiveor Bipolar Disorder
Alcoholism
Drug or Substance Abuse
Learning Disabilities
Other issues requiring
hospitalization/treatment with
psychotropic medication
Muscles/Bones/Joints
(check here if no to all )
Muscular Dystrophy
Other chronicmuscle disease
Auto Immune Diseases
(i.e. Lupus)
Marfan Syndrome
Arthritis
Gout
Sight/Sound/Smell
(check here if no to all )
Deafness Before Age 60
Deformity of the Ear
Cataracts Before Age 60
Blindness
Glaucoma
Retinoblastoma
Any other sight/sound/smell
impairments
Vision
Please note if any family
member wears glasses,contacts or had correctiveeye surgery (LASIX).
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8/10/2019 DEB USA Egg Donor Application
14/17
3-
"#$#% &'() ***************
You Child Mother Father Bother Sister
Grand-
parent
Aunt/
Uncle
1st
Cousin Comments
Skin
(check here if no to all )
Albinism
Pigmentation Disorders
Neurofibromatosis
Other Skin Disorders
Cancer
(check here if no to all )
Breast
Ovarian
Colon
Skin
Thyroid
Cervical
Uterine
Lung Cancer
Prostate or Testicular
Genetic Disease Disorders
(check here if no to all )
Cystic Fibrosis
Sickle Cell Anemia
Tay Sachs
Canavan
Gaucher
Other:
Other Medical Conditions
(check here if no to all )
Birth Defects
Early Death(Under Age 51)
Genetic Disorder
Club Feet
Cleft lip or Palate
Any other Cancer
Any other Condition
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8/10/2019 DEB USA Egg Donor Application
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3.
"#$#% &'() ***************
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Explain the reason for wanting to donate your eggs :
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Describe your personality, character and temperament:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
What physical, artistic, intellectual or social abilities do you feel best about?
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
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8/10/2019 DEB USA Egg Donor Application
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"#$#% &'() ***************
What are your hobbies, interests, and talents?
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
What are your future plans and goals?
_________________________________________________________________________________________________
_________________________________________________________________________________________________
What are you sorry you did not do?
_________________________________________________________________________________________________
_________________________________________________________________________________________________
What other information would you like a Recipient to know about you?
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
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8/10/2019 DEB USA Egg Donor Application
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