Egg Donor Application When you journey through the process of completing our egg donation application, you’ll have the opportunity to help people realize their deep-seated dreams of becoming parents. You’ll change lives, we thank you for considering the choice of being an egg donor and at Gifted Conceptions, we appreciate you and we can't wait to work with you. Preferred Donation Type Open Anonymous First Time Donor Yes No, I have donated 1. PERSONAL INFORMATION *Non-disclosure to intended parent(s) Legal Full Name * First Name Last Name Nick Name * Date of Birth * Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * Country (###) ### #### Email 2. CHARACTERISTICS Blood Type: Height: Weight: Natural Eye Color: Blue Green Hazel Brown Amber Natural Hair Color: Brown Black Blonde Auburn Red Hair Texture: Straight Curly Wavy Body Type: Option 1 Option 2 Skin Tone: Light Medium Light Medium Medium Dark Dark Your Ethnicity/ Origin: Hispanic and Latino Americans Asian Caucasian Alaska Natives or American Indian African Americans Native Hawaiian or Other Pacific Islander East Indian Middle Eastern or Arabic Multi - Ethnic Jewish Ancestry: Yes No Astrological Sign: Aries Taurus Gemini Cancer Leo Virgo Libra Scorpio Sagittarius Capricorn Aquarius Pisces Favorite Subject: History Mathematics Languages Natural Science Psychology Social Science Technology Talents / Hobbies: Musical Team Sports Individual Sports Culinary Crafts/ Creative / Artistic Computer / Technology Outdoor Recreation Pets Favorite Pet: Dog Cat Bird Fish Reptile Education Level: Bachelor Master Posgraduate Still in school Father's Ancestry Mother's Ancestry Religion: Agnostic, Atheist, Declined to State Buddhist Christian Hindu, Sikh Jewish Muslim Other 3. EDUCATION ACT / SAT Score: High School Graduated / GPA College Graduated / GPA: College Major / Degree: Favorite Subject: Special Talent / Training: 4. LIFESTYLE What are your hobbies? What is your favorite book? Do you exercise? And how often? Your favorite foods? Do you have any artistic talents? Have you done any traveling? What is your earliest childhood memory? 5. MEDICAL HISTORY / SCREENING Is your health condition generally healthy? Yes No List any of your current/ previous health issue(s): Are you currently taking any medication(s)? Yes No List any of your current/ previous medication(s): Are you under a doctor's care? Yes No Do you have any emotional or depression problem? Yes No Do you were corrective lenses? Yes No Do you have normal hearing? Yes No Have you ever taken any growth hormones? Yes No Have you ever taken any non prescribed steoids? Yes No Have you had any plastic surgery? Yes No Have you ever had cancer? Yes No Have you ever done any genetic counseling Yes No Have you done any genetic screening testing to determine if you are a carrier for: Cystic Fibrosis Tay-Sachs Sickle Cells Anemia Metabolism Disorder Other 1) Do you or any family members have a history of drug abuse? Yes No 2) Do you or any family members have a history of alcohol abuse? Yes No 3) Have you or any of your family member have any Allergy problem as: None Medication Allergy Food Allergy Sinusitis Rhinitis Other 4) Have you or any of your family member have any Endocrine problem as: None Diabetes Mellitus Hypoglycemia Hyperthyroidism Hyperparathyroidism Other 5) Have you or any of your family member have any Blood & Circulation problem as: None Anemia Hemophilia Leukemia Lymphoma Other 6) Have you or any of your family member have any Eye/Ear/Nose/Throat problem as: None Cataracts Malformation Macular Degeneration Joint Dysfunction Other 7) Have you or any of your family member have any Cardiovascular problem as: None Angina Heart Failure Hypertension Stroke Other 8) Have you or any of your family member have any Cardiovascular problem as: None Angina Heart Failure Hypertension Stroke Other 9) Have you or any of your family member have any Digestion problem as: None Cirrhosis Hepatitis, Viral Pancreatitis Gallbladder Disease Other 10) Have you or any of your family member have any Skin problem as: None Acne Erythema Hirsutism Psoriasis Other 11) Have you or any of your family member have any Musculoskeletal problem as: None Gout Lupus Arthritis Osteoporosis Other 12) Have you or any of your family member have any Psychology problem as: None Alcoholism Dementia Depression PTSD Other 13) Have you or any of your family member have any Reproductive problem as: None PCOS Ovarian Cysts Vaginitis Endometriosis Other 14) Have you or any of your family member have any Sexually Trasmitted problem as: None Herpes Syphilis Chlamydia/Gonorrhea Human Papillomavirus (HPV) Other 15) Have you or any of your family member have any Infectious / Chronic problem as: None HIV and AIDS Tuberculosis Hepatitis B Herpes Zoster Virus Other 16) Any known cancer condition as: None Breast Cancer Cervical Cancer Colorectal Cancer Skin Cancer Other 8. REPRODUCTIVE HISTORY How old were you at your first menstrual cycle? When was your last menstrual period? MM DD YYYY How long is your menstrual period? Do you have regular cycle? Yes No How many days between periods? Do you currently take birth control pills? Or use contraceptive ring? Use Birth Control Pill Use Contraceptive Ring No, I have never used birth control pill or ring When was your last PAP SMEAR? MM DD YYYY Was the result normal? Yes No Have you ever had an abnormal PAP? Yes No Have you ever been treated for a STD? Yes No Have you ever given sex to exchange for money or drugs? Yes No Have you ever injected non therapeutic drugs? Yes No Are you currently pregnant? Yes No Have you had any abortion? Yes No Have you had any miscarriage? Yes No Have you had any ectopic pregnancy? Yes No Have you been told you are infertile? Yes No Have anyone in your family had infertility problems? Yes No Do you have children of your own? Yes No 9. PREVIOUS DONATION RECORD How many times have you donated before? 1) Date of Most Recent donation cycle / Clinic Name # of Eggs retrieved / # of Mature Eggs / # of Embryos 2) Date of any previous donation cycle / Clinic Name # of Eggs retrieved / # of Mature Eggs / # of Embryos 3) Date of any previous donation cycle / Clinic Name # of Eggs retrieved / # of Mature Eggs / # of Embryos 4) Date of any previous donation cycle / Clinic Name # of Eggs retrieved / # of Mature Eggs / # of Embryos 5) Date of any previous donation cycle / Clinic Name # of Eggs retrieved / # of Mature Eggs / # of Embryos 10. UPLOAD DOCUMENTS Thank you! We will call for the next steps.
