deb usa egg donor application

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.


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?

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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: _____________


3/17

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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: _________________________

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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? __________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________


4/17

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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

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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? ____________________________________________________


5/17

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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: _______________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

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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? ____________________________________


6/17

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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: _______




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? __________________


7/17

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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.


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


9/17

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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


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: _______________________________________________________________________________

_________________________________________________________________________________________________


11/17

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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


Anemia

Hemophilia or otherbleeding disorder

HIV/AIDS

Leukemia

Other Blood Disorder

Respiratory/Lungs


Asthma

Emphysema

Tuberculosis

Gastrointestinal


Ulcer of Stomach/Duodenum

Ulcerative Colitis

Hepatitis - A,B or C

Crohn's Disease

Inflammatory Bowel Disease

Any other cancer/problemwith digestive system


12/17

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Aunt/Uncle

1st

Cousin Comments

Metabolic/Endocrine


Diabetes

(Requiring Insulin)

Diabetes(Not Requiring Insulin)

Thyroid Disease(Hypo/Hyper)

Adrenal Gland Disorder

PKU or InheritedMetabolism Disorder

Dwarfism

Urinary


Kidney DiseaseOther disease/defectof urinary tract

(urethra, bladder, ureter)

Genital/Reproductive


Infertility

Miscarriage or Stillborn

Uterine Fibroids

Endometriosis

Ovarian Cysts

Other Genitalor Reproductive Diseases

Nervous System


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


13/17

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Aunt/Uncle

1st

Cousin Comments

Mental Healthor Learning Disability


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


Muscular Dystrophy

Other chronicmuscle disease

Auto Immune Diseases

(i.e. Lupus)

Marfan Syndrome

Arthritis

Gout

Sight/Sound/Smell


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).


14/17

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You Child Mother Father Bother Sister

Grand-

parent

Aunt/

Uncle

1st

Cousin Comments

Skin


Albinism

Pigmentation Disorders

Neurofibromatosis

Other Skin Disorders

Cancer


Breast

Ovarian

Colon

Skin

Thyroid

Cervical

Uterine

Lung Cancer

Prostate or Testicular

Genetic Disease Disorders


Cystic Fibrosis

Sickle Cell Anemia

Tay Sachs

Canavan

Gaucher

Other:

Other Medical Conditions


Birth Defects

Early Death(Under Age 51)

Genetic Disorder

Club Feet

Cleft lip or Palate

Any other Cancer

Any other Condition


15/17

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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?

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________


16/17

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What are your hobbies, interests, and talents?

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

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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?

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________


17/17

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deb usa egg donor application

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