First Name
* must provide value
Last Name
* must provide value
Date of Birth
* must provide value
Today M-D-Y
Check all that apply
If other, please specify
* must provide value
Ethnic Origin
* must provide value
Check all that apply
What part(s) of Africa?
* must provide value
What part(s) of the Carribean?
* must provide value
What part(s) of the Middle East?
* must provide value
What part(s) of South America?
* must provide value
What part(s) of East Asia?
* must provide value
What part(s) of South Asia?
* must provide value
What other ethnicity or ethnicities are you?
* must provide value
Address
* must provide value
State
* must provide value
Zip Code
* must provide value
Home Phone
* must provide value
E-mail Address
* must provide value
If you don't have one, write "none"
What are the best ways to contact you?
* must provide value
Check all that apply
How did you hear about our program?
Check all that apply
Have you ever participated in another donor egg program?
* must provide value
Yes
No
Do you have medical/major medical insurance?
* must provide value
Yes
No
Height (in inches)
* must provide value
Note: 5 feet = 60 inches; 6 feet = 72 inches
Weight (in pounds)
* must provide value
How would you characterize your body frame?
* must provide value
Small
Medium
Large
What is your blood type?
* must provide value
A+
A-
B+
B-
AB+
AB-
O+
O-
Don't know
What is your eye color?
* must provide value
Brown
Blue
Hazel
Other
If other, please specify
* must provide value
What is your natural hair color?
* must provide value
Black
Brown
Blonde
Red
Other
If other, please specify
* must provide value
How would you characterize your natural hair?
* must provide value
Check all that apply
At what age did you develop prematurely gray hair?
If other, please specify
* must provide value
What is your skin tone?
* must provide value
Fair
Medium
Olive
Light Brown
Dark Brown
Ebony
Rosy
Other
If other, please specify
* must provide value
How many birthmarks do you have?
* must provide value
0 1 2 3 4 5 6 7 8 9 10 More than 10
How many moles do you have?
* must provide value
0 1 2 3 4 5 6 7 8 9 10 More than 10
Do you have freckles?
* must provide value
Yes
No
What is your handedness?
* must provide value
Right-handed
Left-handed
Ambidextrous
Do you have any piercings?
* must provide value
Yes
No
Date of most recent piercing
* must provide value
Today M-D-Y
Do you have any tattoos?
* must provide value
Yes
No
Date of most recent tattoo
* must provide value
Today M-D-Y
Have you undergone acupuncture in the last year?
* must provide value
Yes
No
What is your marital status?
* must provide value
Single
Married
Separated
Divorce
Are you currently in a relationship?
* must provide value
Yes
No
Is your relationship monogamous?
* must provide value
Yes
No
What is your educational background (check all that apply)
Check if you attended at all, even if you did not graduate
If other, please describe
* must provide value
Number of years of high school completed
Less than 1
1
2
3
4
Did you take the SAT?
* must provide value
Yes
No
SAT score
* must provide value
If you do not recall, write "do not recall"
Number of years of college completed
* must provide value
Less than 1
1
2
3
4
College Degree(s) Attained
Check all that apply
What degree are you working towards?
* must provide value
Highest GPA possible
Number of years of graduate school completed
* must provide value
Less than 1
1
2
3
4
5 or more
Graduate school GPA
* must provide value
Graduate school major
* must provide value
What is your employment background
* must provide value
Currently employed
Not employed now, but have been previously
Never employed
Current occupation
* must provide value
For how long have you been employed in your current occupation? (in years)
* must provide value
Previous occupation
* must provide value
If none, write "none"
How long were you employed in your previous occupation? (in years)
* must provide value
If you do not have a previous occupation, write "0"
Were you born in the United States?
* must provide value
Yes
No
Have you ever traveled outside of the United States?
* must provide value
Yes
No
Please list the countries with dates in parenthesis
* must provide value
Example: Australia (1/10/10 - 1/20/10), India (1/21/10 - 1/30/10)
Have you ever served in the military?
* must provide value
Yes
No
Do you smoke cigarettes?
* must provide value
Yes
No
How many cigarettes per day do you smoke?
* must provide value
Do you drink alcoholic beverages?
* must provide value
Yes
No
Which alcoholic drinks do you consume?
* must provide value
Check all that apply
How many servings of liquor do you drink?
* must provide value
At least 2-3 drinks per day
5-6 drinks per week
2-3 drinks per week
2-3 drinks per month
1 drink per month or less
Serving = 1 ounce
How many servings of beer do you drink per day?
* must provide value
At least 2-3 drinks per day
5-6 drinks per week
2-3 drinks per week
2-3 drinks per month
1 drink per month or less
Serving = 12 ounces
How many servings of wine do you drink per day?
* must provide value
At least 2-3 drinks per day
5-6 drinks per week
2-3 drinks per week
2-3 drinks per month
1 drink per month or less
Serving = 4 ounces
If other, please specify the type of alcohol
* must provide value
How many servings of "other" alcohol do you drink per day?
* must provide value
At least 2-3 drinks per day
5-6 drinks per week
2-3 drinks per week
2-3 drinks per month
1 drink per month or less
If you do not now, was there ever a time when you drank 3 or more servings of alcohol per day?
* must provide value
Yes
No
Currently drink 3 or more servings per day
How many servings per day?
* must provide value
How long ago? (in years)
* must provide value
For how many months?
* must provide value
Have you ever used IV (intravenous) drugs, not administered by a health professional?
* must provide value
Yes
No
Which of the following drugs have you ever used or do you currently use now?
* must provide value
Frequency of marijuana use
* must provide value
At least 2-3 times per day
5-6 times per week
2-3 times per week
2-3 times per month
1 time per month or less
Frequency of cocaine use
* must provide value
At least 2-3 times per day
5-6 times per week
2-3 times per week
2-3 times per month
1 time per month or less
Frequency of barbiturates use
* must provide value
At least 2-3 times per day
5-6 times per week
2-3 times per week
2-3 times per month
1 time per month or less
Frequency of narcotics use
* must provide value
At least 2-3 times per day
5-6 times per week
2-3 times per week
2-3 times per month
1 time per month or less
Frequency of amphetamine use
* must provide value
At least 2-3 times per day
5-6 times per week
2-3 times per week
2-3 times per month
1 time per month or less
Frequency of hallucinogens use
* must provide value
At least 2-3 times per day
5-6 times per week
2-3 times per week
2-3 times per month
1 time per month or less
Frequency of tranquilizers use
* must provide value
At least 2-3 times per day
5-6 times per week
2-3 times per week
2-3 times per month
1 time per month or less
Frequency of anti-depressants use
* must provide value
At least 2-3 times per day
5-6 times per week
2-3 times per week
2-3 times per month
1 time per month or less
Frequency of PCP use
* must provide value
At least 2-3 times per day
5-6 times per week
2-3 times per week
2-3 times per month
1 time per month or less
Frequency of inhalants use
* must provide value
At least 2-3 times per day
5-6 times per week
2-3 times per week
2-3 times per month
1 time per month or less
Have you ever been admitted to a hospital for substance or alcohol abuse?
* must provide value
Yes
No
At what age were you admitted?
* must provide value
For how many days were you in the hospital?
* must provide value
Were you admitted more than once?
* must provide value
Yes
No
Have you ever been treated for mental health issues?
* must provide value
Yes
No
What were you treated for?
* must provide value
How long ago were you treated?
* must provide value
For how long were you treated?
* must provide value
Were you hospitalized?
* must provide value
Yes
No
How would you characterize your diet?
* must provide value
Vegetarian
Non-Vegetarian
Vegan
How would you describe your eating habits?
* must provide value
Poor eating habits
Average eating habits
Good eating habits
How often do you exercise?
* must provide value
Regularly
Sometimes
Seldom
Never
What types of exercise do you participate in?
* must provide value
If you do not exercise, write "none"
How would you characterize your dental health?
* must provide value
Poor
Fair
Good
Excellent
How would you characterize your vision?
* must provide value
Poor
Fair
Good
Excellent
Please characterize your hearing
* must provide value
Poor
Fair
Good
Excellent
Do you have or have you had:
* must provide value
Check all that apply
Please specify your hearing problem(s)
* must provide value
Please specify the nature of your use of a hearing aid
* must provide value
What type of surgery did you have to correct your hearing?
* must provide value
How old (in years) were you when you had the surgery?
* must provide value
If another vision aid, please describe.
* must provide value
Do you use a vision aid because you are:
* must provide value
Near-sighted
Far-sighted
Other
If another vision impairment, please describe.
* must provide value
Please specify the type of surgery to correct your vision that you underwent
* must provide value
How old (in years) were you when you had this vision surgery?
* must provide value
Do you have any allergies?
* must provide value
Yes
No
Please describe your allergies.
* must provide value
What kinds of reactions have you had?
* must provide value
Have you outgrown any allergies?
* must provide value
Yes
No
Please specify what allergies you have outgrown
* must provide value
At what age did you outgrow these allergies?
* must provide value
Have you ever had surgery in the past?
* must provide value
Yes
No
How many surgeries have you had in the past?
* must provide value
1 2 3 4 5 More than 5
Surgery 1 (Type)
* must provide value
Surgery 1 (Reason)
* must provide value
Surgery 1 (Year)
* must provide value
Surgery 2 (Type)
* must provide value
Surgery 2 (Reason)
* must provide value
Surgery 2 (Year)
* must provide value
Surgery 3 (Type)
* must provide value
Surgery 3 (Reason)
* must provide value
Surgery 3 (Year)
* must provide value
Surgery 4 (Type)
* must provide value
Surgery 4 (Reason)
* must provide value
Surgery 4 (Year)
* must provide value
Surgery 5 (Type)
* must provide value
Surgery 5 (Reason)
* must provide value
Surgery 5 (Year)
* must provide value
Please describe any additional surgeries
* must provide value
Have you ever been hospitalized for any reason? (not including surgeries)
* must provide value
Yes
No
How many times have you been hospitalized? (not including surgeries)
* must provide value
1 2 3 4 5 More than 5
Hospitalization 1 Reason
* must provide value
Hospitalization 1 (Year)
* must provide value
Hospitalization 2 Reason
* must provide value
Hospitalization 2 (Year)
* must provide value
Hospitalization 3 Reason
* must provide value
Hospitalization 3 (Year)
* must provide value
Hospitalization 4 Reason
* must provide value
Hospitalization 4 (Year)
* must provide value
Hospitalization 5 Reason
* must provide value
Hospitalization 5 (Year)
* must provide value
Have you ever had a blood transfusion?
* must provide value
Yes
No
In what year did you have the blood transfusion?
* must provide value
Have you ever had any radiation or x-ray exposure?
* must provide value
Yes
No
In what year did you have the exposure?
* must provide value
Which of the following are you currently taking?
* must provide value
Check all that apply
How many prescription medications are you currently taking?
* must provide value
1 2 3 4 5 More than 5
How many non-prescription medications are you currently taking?
* must provide value
1 2 3 4 5 More than 5
How many herbal supplements are you currently taking?
* must provide value
1 2 3 4 5 More than 5
Prescription Medication 1
* must provide value
Dose (Prescription Medication 1)
* must provide value
Reason (Prescription Medication 1)
* must provide value
For how long have you been taking Prescription Medication 1?
* must provide value
Prescription Medication 2
* must provide value
Dose (Prescription Medication 2)
* must provide value
Reason (Prescription Medication 2)
* must provide value
For how long have you been taking Prescription Medication 2?
* must provide value
Prescription Medication 3
* must provide value
Dose (Prescription Medication 3)
* must provide value
Reason (Prescription Medication 3)
* must provide value
For how long have you been taking Prescription Medication 3?
* must provide value
Prescription Medication 4
* must provide value
Dose (Prescription Medication 4)
* must provide value
Reason (Prescription Medication 4)
* must provide value
For how long have you been taking Prescription Medication 4?
* must provide value
Prescription Medication 5
* must provide value
Dose (Prescription Medication 5)
* must provide value
Reason (Prescription Medication 5)
* must provide value
For how long have you been taking Prescription Medication 5?
* must provide value
If you are taking more than 5 prescription medications, please describe the rest here
* must provide value
Non-Prescription Medication 1
* must provide value
Dose (Non-Prescription Medication 1)
* must provide value
Reason (Non-Prescription Medication 1)
* must provide value
For how long have you been taking Non-Prescription Medication 1?
* must provide value
Non-Prescription Medication 2
* must provide value
Dose (Non-Prescription Medication 2)
* must provide value
Reason (Non-Prescription Medication 2)
* must provide value
For how long have you been taking Non-Prescription Medication 2?
* must provide value
Non-Prescription Medication 3
* must provide value
Dose (Non-Prescription Medication 3)
* must provide value
Reason (Non-Prescription Medication 3)
* must provide value
For how long have you been taking Non-Prescription Medication 3?
* must provide value
Non-Prescription Medication 4
* must provide value
Dose (Non-Prescription Medication 4)
* must provide value
Reason (Non-Prescription Medication 4)
* must provide value
For how long have you been taking Non-Prescription Medication 4?
* must provide value
Non-Prescription Medication 5
* must provide value
Dose (Non-Prescription Medication 5)
* must provide value
Reason (Non-Prescription Medication 5)
* must provide value
For how long have you been taking Non-Prescription Medication 5?
* must provide value
If you are taking more than 5 non-prescription medications, please describe the rest here
* must provide value
Herbal Supplement 1
* must provide value
Dose (Herbal Supplement 1)
* must provide value
Reason (Herbal Supplement 1)
* must provide value
For how long have you been taking Herbal Supplement 1?
* must provide value
Herbal Supplement 2
* must provide value
Dose (Herbal Supplement 2)
* must provide value
Reason (Herbal Supplement 2)
* must provide value
For how long have you been taking Herbal Supplement 2?
* must provide value
Herbal Supplement 3
* must provide value
Dose (Herbal Supplement 3)
* must provide value
Reason (Herbal Supplement 3)
* must provide value
For how long have you been taking Herbal Supplement 3?
* must provide value
Herbal Supplement 4
* must provide value
Dose (Herbal Supplement 4)
* must provide value
Reason (Herbal Supplement 4)
* must provide value
For how long have you been taking Herbal Supplement 4?
* must provide value
Herbal Supplement 5
* must provide value
Dose (Herbal Supplement 5)
* must provide value
Reason (Herbal Supplement 5)
* must provide value
For how long have you been taking Herbal Supplement 5?
* must provide value
If you are taking more than 5 herbal supplements please describe the rest here
* must provide value
How would you describe your sexual history?
* must provide value
Heterosexual
Homosexual
Bisexual
Other
Are you sexually active?
* must provide value
Yes
No
How many sexual partners have you had in the past 12 months?
* must provide value
0 1 2 3 4 5 6 7 8 9 10 More than 10
How many sex partners has your partner had in the past 12 months?
* must provide value
0 1 2 3 4 5 6 7 8 9 10 More than 10
Have you ever been sexually involved with someone who is bisexual?
* must provide value
Yes
No
Do you use contraception
* must provide value
Yes
No
What method of contraception do you use?
* must provide value
How long have you used this method of contraception?
* must provide value
Have you ever used injectable contraception?
* must provide value
Yes
No
What is the most recent year you used injectable contraception?
* must provide value
Have you ever had any of the following:
* must provide value
Check all that apply
In what year did you contract syphilis?
* must provide value
In what year did you contract gonorrhea?
* must provide value
In what year did you contract chlamydia?
* must provide value
In what year did you contract venereal warts?
* must provide value
In what year did you contract herpes?
* must provide value
In what year did you contract Hepatitis A?
* must provide value
In what year did you contract Hepatitis B?
* must provide value
In what year did you contract Hepatitis C?
* must provide value
In what year did you get a pelvic infection?
* must provide value
In what year did you contract non-specific urethritis?
* must provide value
In what year did you contract HPV?
* must provide value
In what year did you contract HIV?
* must provide value
Has your current partner ever had any of the following:
* must provide value
Check all that apply
In what year did your partner contract syphilis?
* must provide value
In what year did your partner contract gonorrhea?
* must provide value
In what year did your partner contract chlamydia?
* must provide value
In what year did your partner contract venereal warts?
* must provide value
In what year did your partner contract herpes?
* must provide value
In what year did your partner contract Hepatitis A?
* must provide value
In what year did your partner contract Hepatitis B?
* must provide value
In what year did your partner contract Hepatitis C?
* must provide value
In what year did your partner contract a pelvic infection?
* must provide value
In what year did your partner contract non-specific urethritis?
* must provide value
In what year did your partner contract HPV?
* must provide value
In what year did your partner contract HIV?
* must provide value
How old were you when you had your first menses?
* must provide value
Are menses regular?
* must provide value
Yes
No
How frequent are your menses? (days per cycle)
* must provide value
Less than 25 days per cycle
25-28 days
28-35 days
More than 35 days
On average, how many days do you bleed?
* must provide value
Type of flow
* must provide value
Heavy
Light
Clots
Other
If other, please specify
* must provide value
Have you ever had infertility issues?
* must provide value
Yes
No
Please explain your infertility issues.
When was your last pap smear? (month and year)
* must provide value
Have you ever had an abnormal pap?
* must provide value
Yes
No
How old were you when you had the abnormal pap?
* must provide value
In what year did you have an abnormal pap?
* must provide value
Please specify in what way the pap was abnormal
* must provide value
When was your last breast exam? (month and year)
* must provide value
Have you ever had a breast mass? (lump)
* must provide value
Yes
No
Did you have treatment for the breast mass?
* must provide value
Yes
No
Have you ever had a mammogram?
* must provide value
Yes
No
When was your last mammogram? (month and year)
* must provide value
How many times have you been pregnant?
* must provide value
0 1 2 3 4 5 More than 5
Year of Pregnancy
* must provide value
Pregnancy Outcome
* must provide value
Live Birth
Miscarriage
Ectopic
Termination
Mode of Delivery
* must provide value
Vaginal
C-section
Sex of Child
* must provide value
Female
Male
Birthweight (in pounds)
* must provide value
Ex. 6.5
Was the child healthy at birth?
* must provide value
Yes
No
Please describe the child's condition at birth.
* must provide value
Did you experience any of the following complications? (if none, leave blank)
Check all that apply
Year of Pregnancy 1
* must provide value
Pregnancy 1 Outcome
* must provide value
Live Birth
Miscarriage
Ectopic
Termination
Mode of Delivery 1
* must provide value
Vaginal
C-section
Sex of Child (Pregnancy 1)
* must provide value
Female
Male
Birthweight (Pregnancy 1, in pounds)
* must provide value
Ex. 6.5
Was the child healthy at birth? (Pregnancy 1)
* must provide value
Yes
No
Did you experience any of the following complications? (Pregnancy 1). If none, leave blank
Check all that apply
Year of Pregnancy 2
* must provide value
Pregnancy 2 Outcome
* must provide value
Live Birth
Miscarriage
Ectopic
Termination
Mode of Delivery 2
* must provide value
Vaginal
C-section
Sex of Child (Pregnancy 2)
* must provide value
Female
Male
Birthweight (Pregnancy 2, in pounds)
* must provide value
Ex. 6.5
Was the child healthy at birth? (Pregnancy 2)
* must provide value
Yes
No
Did you experience any of the following complications? (Pregnancy 2). If none, leave blank
Check all that apply
Year of Pregnancy 3
* must provide value
Pregnancy 3 Outcome
* must provide value
Live Birth
Miscarriage
Ectopic
Termination
Mode of Delivery 3
* must provide value
Vaginal
C-section
Sex of Child (Pregnancy 3)
* must provide value
Female
Male
Birthweight (Pregnancy 3, in pounds)
* must provide value
Ex. 6.5
Was the child healthy at birth? (Pregnancy 3)
* must provide value
Yes
No
Did you experience any of the following complications? (Pregnancy 3). If none, leave blank
Check all that apply
Year of Pregnancy 4
* must provide value
Pregnancy 4 Outcome
* must provide value
Live Birth
Miscarriage
Ectopic
Termination
Mode of Delivery 4
* must provide value
Vaginal
C-section
Sex of Child (Pregnancy 4)
* must provide value
Female
Male
Birthweight (Pregnancy 4, in pounds)
* must provide value
Ex. 6.5
Was the child healthy at birth? (Pregnancy 4)
* must provide value
Yes
No
Did you experience any of the following complications? (Pregnancy 4). If none, leave blank
Check all that apply
Year of Pregnancy 5
* must provide value
Pregnancy 5 Outcome
* must provide value
Live Birth
Miscarriage
Ectopic
Termination
Mode of Delivery 5
* must provide value
Vaginal
C-section
Sex of Child (Pregnancy 5)
* must provide value
Female
Male
Birthweight (Pregnancy 5, in pounds)
* must provide value
Ex. 6.5
Was the child healthy at birth? (Pregnancy 5)
* must provide value
Yes
No
Did you experience any of the following complications? (Pregnancy 5). If none, leave blank
Check all that apply
Please describe each pregnancy after the fifth
* must provide value
How many living children do you have?
* must provide value
0 1 2 3 4 5 More than 5
Date of birth (Child 1)
* must provide value
Today M-D-Y
Sex (Child 1)
* must provide value
Female
Male
Is Child 1:
* must provide value
Biological child
Stepchild
Adopted child
Does Child 1 live with you?
* must provide value
Yes
No
Date of birth (Child 2)
* must provide value
Today M-D-Y
Sex (Child 2)
* must provide value
Female
Male
Is Child 2:
* must provide value
Biological child
Stepchild
Adopted child
Does Child 2 live with you?
* must provide value
Yes
No
Date of birth (Child 3)
* must provide value
Today M-D-Y
Sex (Child 3)
* must provide value
Female
Male
Is Child 3:
* must provide value
Biological child
Stepchild
Adopted child
Does Child 3 live with you?
* must provide value
Yes
No
Date of birth (Child 4)
* must provide value
Today M-D-Y
Sex (Child 4)
* must provide value
Female
Male
Is Child 4:
* must provide value
Biological child
Stepchild
Adopted child
Does Child 4 live with you?
* must provide value
Yes
No
Date of birth (Child 5)
* must provide value
Today M-D-Y
Sex (Child 5)
* must provide value
Female
Male
Is Child 5:
* must provide value
Biological child
Stepchild
Adopted child
Does Child 5 live with you?
* must provide value
Yes
No
Please specify what other children you have
* must provide value
Do you have any children that are now deceased?
* must provide value
Yes
No
What was the cause of death?
* must provide value
Are you adopted?
* must provide value
Yes
No
Can you describe the physical characteristics of your biological parents and/or siblings?
* must provide value
Yes
No
How many blood siblings are there in your immediate family (not including yourself)?
* must provide value
0 1 2 3 4 5 More than 5 Don't know
How many blood sisters(not including yourself)?
* must provide value
0 1 2 3 4 5 More than 5 Don't know
How many blood brothers?
* must provide value
0 1 2 3 4 5 More than 5 Don't know
Are there any twins or triplets in your family?
* must provide value
Yes
No
How many sets of twins?
* must provide value
1 2 3 More than 3 0
How many sets of triplets?
* must provide value
1 2 3 More than 3 0
What relationship to you are the twins?
* must provide value
What relationship to you are the triplets?
* must provide value
Do you have a family history of genetic abnormalities or birth defects?
* must provide value
Yes
No
Please specify what genetic abnormalities or birth defects.
* must provide value
Please list your mother's age, race/ethnicity, eye color, hair color, and complexion (separate by commas).
* must provide value
Example: 50, Asian, Brown, Brown, Medium
Mother's height (in inches)
* must provide value
Note: 5 feet = 60 inches; 6 feet = 72 inches
Mother's body type
* must provide value
Small
Medium
Large
Don't know
Does your mother wear glasses or contact lenses?
* must provide value
Yes
No
Don't know
Please list your father's age, race/ethnicity, eye color, hair color, and complexion (separate by commas).
* must provide value
Father's Height (in inches)
* must provide value
Note: 5 feet = 60 inches; 6 feet = 72 inches
Father's body type
* must provide value
Small
Medium
Large
Don't know
Does your father wear glasses or contact lenses?
* must provide value
Yes
No
Don't know
Please list your maternal grandmother's age, race/ethnicity, eye color, hair color, and complexion (separate by commas).
* must provide value
If you don't know, write "don't know"
Maternal Grandmother's Height (in inches)
* must provide value
Note: 5 feet = 60 inches
Maternal grandmother's body type
* must provide value
Small
Medium
Large
Don't know
Does your maternal grandmother wear glasses or contact lenses?
* must provide value
Yes
No
Don't know
Please list your maternal grandfather's age, race/ethnicity, eye color, hair color, and complexion (separate by commas).
* must provide value
If you don't know, write "don't know"
Maternal Grandfather's Height (in inches)
* must provide value
Note: 5 feet = 60 inches
Maternal grandfather's body type
* must provide value
Small
Medium
Large
Don't know
Does your maternal grandfather wear glasses or contact lenses?
* must provide value
Yes
No
Don't know
Please list your paternal grandmother's age, race/ethnicity, eye color, hair color, and complexion (separate by commas).
* must provide value
If you don't know, write "don't know"
Paternal Grandmother's Height (in inches)
* must provide value
Note: 5 feet = 60 inches
Paternal grandmother's body type
* must provide value
Small
Medium
Large
Don't know
Does your paternal grandmother wear glasses or contact lenses?
* must provide value
Yes
No
Don't know
Please list your paternal grandfather's age, race/ethnicity, eye color, hair color, and complexion (separate by commas).
* must provide value
If you don't know, write "don't know"
Paternal Grandfather's Height (in inches)
* must provide value
Note: 5 feet = 60 inches
Paternal grandfather's body type
* must provide value
Small
Medium
Large
Don't know
Does your paternal grandfather wear glasses or contact lenses?
* must provide value
Yes
No
Don't know
Please list brother one's age, race/ethnicity, eye color, hair color, and complexion (separate by commas).
* must provide value
If you don't know, write "don't know"
Brother one's Height (in inches)
* must provide value
Note: 5 feet = 60 inches
Brother one's body type
* must provide value
Small
Medium
Large
Don't know
Does brother one wear glasses or contact lenses?
* must provide value
Yes
No
Don't know
Please list brother two's age, race/ethnicity, eye color, hair color, and complexion (separate by commas).
* must provide value
Brother two's height (in inches)
* must provide value
Brother two's body type
* must provide value
Small
Medium
Large
Don't know
Does brother two wear glasses or contact lenses?
* must provide value
Yes
No
Don't know
Please list brother three's age, race/ethnicity, eye color, hair color, and complexion (separate by commas).
* must provide value
Brother three's height (in inches)
* must provide value
Brother three's body type
* must provide value
Small
Medium
Large
Don't know
Does brother three wear glasses or contact lenses?
* must provide value
Yes
No
Don't know
Please list brother four's age, race/ethnicity, eye color, hair color, and complexion (separate by commas).
* must provide value
Brother four's height (in inches)
* must provide value
Brother four's body type
* must provide value
Small
Medium
Large
Don't know
Does brother four wear glasses or contact lenses?
* must provide value
Yes
No
Don't know
Please list brother five's age, race/ethnicity, eye color, hair color, and complexion (separate by commas).
* must provide value
Brother five's height (in inches)
* must provide value
Brother five's body type
* must provide value
Small
Medium
Large
Don't know
Does brother five wear glasses or contact lenses?
* must provide value
Yes
No
Don't know
If you have more than five brothers, please provide characteristics for any additional brothers for whom you have not already done so.
* must provide value
Please list sister one's age, race/ethnicity, eye color, hair color, and complexion (separate by commas).
* must provide value
Sister one's Height (in inches)
* must provide value
Sister one's body type
* must provide value
Small
Medium
Large
Don't know
Does sister one wear glasses or contact lenses?
* must provide value
Yes
No
Don't know
Please list sister two's age, race/ethnicity, eye color, hair color, and complexion (separate by commas).
* must provide value
Sister two's height (in inches)
* must provide value
Sister two's body type
* must provide value
Small
Medium
Large
Don't know
Does sister two wear glasses or contact lenses?
* must provide value
Yes
No
Don't know
Please list sister three's age, race/ethnicity, eye color, hair color, and complexion (separate by commas).
* must provide value
Sister three's height (in inches)
* must provide value
Sister three's body type
* must provide value
Small
Medium
Large
Don't know
Does sister three wear glasses or contact lenses?
* must provide value
Yes
No
Don't know
Please list sister four's age, race/ethnicity, eye color, hair color, and complexion (separate by commas).
* must provide value
Sister four's height (in inches)
* must provide value
Sister four's body type
* must provide value
Small
Medium
Large
Don't know
Does sister four wear glasses or contact lenses?
* must provide value
Yes
No
Don't know
Please list sister five's age, race/ethnicity, eye color, hair color, and complexion (separate by commas).
* must provide value
Sister five's height (in inches)
* must provide value
Sister five's body type
* must provide value
Small
Medium
Large
Don't know
Does sister five wear glasses or contact lenses?
* must provide value
Yes
No
Don't know
If you have more than five sisters please provide characteristics for any additional sisters for whom you have not already done so.
* must provide value
Have any of the following people in your family died?
* must provide value
Check all that apply
How many of your brothers have died?
* must provide value
1 2 3 4 5 More than 5
How many of your sisters have died?
* must provide value
1 2 3 4 5 More than 5
How many of your maternal aunts have died?
* must provide value
1 2 3 4 5 More than 5
How many of your maternal uncles have died?
* must provide value
1 2 3 4 5 More than 5
How many of your paternal aunts have died?
* must provide value
1 2 3 4 5 More than 5
How many of your paternal uncles have died?
* must provide value
1 2 3 4 5 More than 5
Age of Mother at Death, Cause of Death
* must provide value
Example: 85, Cause
Age of Father at Death, Cause of Death
* must provide value
Example: 85, Cause
Age of Maternal grandmother at Death, Cause of Death
* must provide value
Example: 85, Cause
Age of Maternal Grandfather at Death, Cause of Death
* must provide value
Example: 85, Cause
Age of Paternal grandmother at Death, Cause of Death
* must provide value
Example: 85, Cause
Age of Paternal grandfather at Death, Cause of Death
* must provide value
Example: 85, Cause
Age of Brother 1 at Death, Cause of Death
* must provide value
Example: 85, Cause
Age of Brother 2 at Death, Cause of Death
* must provide value
Example: 85, Cause
Age of Brother 3 at Death, Cause of Death
* must provide value
Example: 85, Cause
Age of Brother 4 at Death, Cause of Death
* must provide value
Example: 85, Cause
Age of Brother 5 at Death, Cause of Death
* must provide value
Example: 85, Cause
If more than 5 brothers have died, please make note of any brothers who have died that you have not already listed.
* must provide value
Age of Sister 1 at Death, Cause of Death
* must provide value
Example: 85, Cause
Age of Sister 2 at Death, Cause of Death
* must provide value
Example: 85, Cause
Age of Sister 3 at Death, Cause of Death
* must provide value
Example: 85, Cause
Age of Sister 4 at Death, Cause of Death
* must provide value
Example: 85, Cause
Age of Sister 5 at Death, Cause of Death
* must provide value
Example: 85, Cause
If more than 5 sisters have died, please make note of any sisters who have died that you have not already listed.
* must provide value
Age of Maternal Aunt 1 at Death, Cause of Death
* must provide value
Example: 85, Cause
Age of Maternal Aunt 2 at Death, Cause of Death
* must provide value
Example: 85, Cause
Age of Maternal Aunt 3 at Death, Cause of Death
* must provide value
Example: 85, Cause
Age of Maternal Aunt 4 at Death, Cause of Death
* must provide value
Example: 85, Cause
Age of Maternal Aunt 5 at Death, Cause of Death
* must provide value
Example: 85, Cause
If more than 5 maternal aunts have died, please make note of any who have died that you have not already listed.
* must provide value
Age of Maternal Uncle 1 at Death, Cause of Death
* must provide value
Example: 85, Cause
Age of Maternal Uncle 2 at Death, Cause of Death
* must provide value
Example: 85, Cause
Age of Maternal Uncle 3 at Death, Cause of Death
* must provide value
Example: 85, Cause
Age of Maternal Uncle 4 at Death, Cause of Death
* must provide value
Example: 85, Cause
Age of Maternal Uncel 5 at Death, Cause of Death
* must provide value
Example: 85, Cause
If more than 5 maternal uncles have died, please make note of any who have died that you have not already listed.
* must provide value
Age of Paternal Aunt 1 at Death, Cause of Death
* must provide value
Example: 85, Cause
Age of Paternal Aunt 2 at Death, Cause of Death
* must provide value
Example: 85, Cause
Age of Paternal Aunt 3 at Death, Cause of Death
* must provide value
Example: 85, Cause
Age of Paternal Aunt 4 at Death, Cause of Death
* must provide value
Example: 85, Cause
Age of Paternal Aunt 5 at Death, Cause of Death
* must provide value
Example: 85, Cause
If more than 5 paternal aunts have died, please make note of any who have died that you have not already listed.
* must provide value
Age of Paternal Uncle 1 at Death, Cause of Death
* must provide value
Example: 85, Cause
Age of Paternal Uncle 2 at Death, Cause of Death
* must provide value
Example: 85, Cause
Age of Paternal Uncle 3 at Death, Cause of Death
* must provide value
Example: 85, Cause
Age of Paternal Uncle 4 at Death, Cause of Death
* must provide value
Example: 85, Cause
Age of Paternal Uncle 5 at Death, Cause of Death
* must provide value
Example: 85, Cause
If more than 5 paternal uncles have died, please make note of any who have died that you have not already listed.
* must provide value
Have you ever been tested for the following?
* must provide value
Check all that apply
Which of the following was your test result for Canavan's Disease?
* must provide value
Carrier
Non-carrier
Unknown
Which of the following was your test result for Tay-Sach's Disease?
* must provide value
Carrier
Non-carrier
Unknown
Which of the following was your test result for Sickle Cell Disease?
* must provide value
Carrier
Non-carrier
Unknown
Which of the following was your test result for Cystic Fibrosis?
* must provide value
Carrier
Non-carrier
Unknown
Which of the following was your test result for Thalassemia?
* must provide value
Carrier
Non-carrier
Unknown
Do you have any current health/medical problems or conditions?
* must provide value
Yes
No
Please specify
* must provide value
Please check any of the following toxins that you have ever been exposed to:
* must provide value
In what year were you exposed to this toxic chemical?
* must provide value
How often were you exposed to this toxic chemical?
* must provide value
What type of toxic chemical were you exposed to?
* must provide value
In what year were you exposed to this spray?
* must provide value
How often were you exposed to this spray?
* must provide value
What type of spray were you exposed to?
* must provide value
In what year were you exposed to fumes/exhaust?
* must provide value
How often were you exposed to fumes/exhaust?
* must provide value
What type of fumes/exhaust were you exposed to?
* must provide value
In what year were you exposed to lead/lead products?
* must provide value
How often were you exposed to lead/lead products?
* must provide value
What type of lead/lead products were you exposed to?
* must provide value
In what year were you exposed to asbestos/asbestos products?
* must provide value
How often were you exposed to asbestos/asbestos products?
* must provide value
What type of asbestos/asbestos products were you exposed to?
* must provide value
In what year were you exposed to cleaning solutions?
* must provide value
How often were you exposed to cleaning solutions?
* must provide value
What type of cleaning solution(s) were you exposed to?
* must provide value
Heart
* must provide value
Please identify who in your family has had a stroke.
* must provide value
Please identify who in your family has had a heart attack.
* must provide value
Please identify who in your family has had heart disease (at birth)
* must provide value
Please identify who in your family has had heart disease (other).
* must provide value
Please identify who in your family has had hardening of the arteries.
* must provide value
Please identify who in your family has had high blood pressure.
* must provide value
Please identify who in your family has had high cholesterol.
* must provide value
Please identify who in your family has had a heart malformation.
* must provide value
Blood
* must provide value
Please identify who in your family has had anemia.
* must provide value
Please identify who in your family has had sickle cell anemia.
* must provide value
Please identify who in your family has had hemophilia.
* must provide value
Please identify who in your family has had another clotting disorder.
* must provide value
Please specify what type of blood clotting disorder.
* must provide value
Please identify who in your family has leukemia.
* must provide value
Please identify who in your family has had HIV virus.
* must provide value
Please identify who in your family has had a lymphoma.
* must provide value
Please identify who in your family has had an immune deficiency.
* must provide value
Please identify who in your family has had another blood disorder.
* must provide value
Please specify what type of blood disorder.
* must provide value
Please identify who in your family has had hay fever or another environmental allergy.
* must provide value
Please identify who in your family has had asthma.
* must provide value
Please identify who in your family has had emphysema.
* must provide value
Please identify who in your family has had tuberculosis.
* must provide value
Please identify who in your family has had lung cancer.
* must provide value
Please identify who in your family has had pneumonia.
* must provide value
Please identify who in your family has had another lung disease.
* must provide value
Please specify what type of lung disease.
* must provide value
Gastrointestinal
* must provide value
Please identify who in your family has had ulcer, stomach, or duodenum disease.
* must provide value
Please identify who in your family has had hepatitis A.
* must provide value
Please identify who in your family has had hepatitis B.
* must provide value
Please identify who in your family has had hepatitis C.
* must provide value
Please identify who in your family has had cirrhosis.
* must provide value
Please identify who in your family has had another liver disease.
* must provide value
Please specify what type of liver disease.
* must provide value
Please identify who in your family has had colon cancer.
* must provide value
Please identify who in your family has had ulcerative colitis.
* must provide value
Please identify who in your family has had Crohn's disease.
* must provide value
Please identify who in your family has had intestinal cancer.
* must provide value
Please identify who in your family has had a developmental disorder of the stomach or intestine
* must provide value
Please identify who in your family has had a pyloric disorder.
* must provide value
Please identify who in your family has had a rectal disorder.
* must provide value
Please identify who in your family has had any other cancer/problem of the digestive system.
* must provide value
Please specify what type of cancer/problem of the digestive system.
* must provide value
Endocrine
* must provide value
Please identify who in your family has had diabetes mellitus.
* must provide value
Please identify who in your family has had hypoglycemia.
* must provide value
Please identify who in your family has had thyroid cancer.
* must provide value
Please identify who in your family has had thyroid disease.
* must provide value
Please identify who in your family has had goiter.
* must provide value
Please identify who in your family has had adrenal dysfunction or disorder
* must provide value
Please identify who in your family has had hyperactivity.
* must provide value
Please identify who in your family has had hormonal dysfunction.
* must provide value
Urinary
* must provide value
Please identify who in your family has had polycistic kidney disease.
* must provide value
Please identify who in your family has had another kidney disease.
* must provide value
Please specify what type of kidney disease.
* must provide value
Please identify who in your family has had another disease of the urinary tract (Urethra, bladder)
* must provide value
Please specify what type of disease of the urinary tract (Urethra, bladder)
* must provide value
Reproductive
* must provide value
Please identify who in your family has had an undescended testicle.
* must provide value
Please identify who in your family has had hermaphroditism/ambiguous genitals.
* must provide value
Please identify who in your family has had hypospadias.
* must provide value
Please identify who in your family has had prostate cancer.
* must provide value
Please identify who in your family has had testicular cancer.
* must provide value
Please identify who in your family has had endometriosis.
* must provide value
Please identify who in your family has had uterine fibroid(s).
* must provide value
Please identify who in your family has had chronic vaginitis.
* must provide value
Please identify who in your family has had ovarian cysts.
* must provide value
Please identify who in your family has had polycistic ovaries.
* must provide value
Please identify who in your family has had cancer of the cervix, overies or uterus.
* must provide value
Please identify who in your family has had 2 or more miscarriages.
* must provide value
Please identify who in your family has had stillborn births.
* must provide value
Please identify who in your family has had death of a newborn infant.
* must provide value
Neurology
* must provide value
Please identify who in your family has had migraines.
* must provide value
Please identify who in your family has had mental retardation.
* must provide value
Please identify who in your family has had Down's Syndrome.
* must provide value
Please identify who in your family has had senility before age 50.
* must provide value
Please identify who in your family has had multiple sclerosis.
* must provide value
Please identify who in your family has had cerebral palsy.
* must provide value
Please identify who in your family has had epilepsy.
* must provide value
Please identify who in your family has had seizure/convulsive disorder.
* must provide value
Please identify who in your family has had hydrocephalus (Water on the Brain)
* must provide value
Please identify who in your family has had Spina Bifita/Neural Tube Defect
* must provide value
Please describe (spina bifita/neural tube defect).
* must provide value
Please identify who in your family has had spinal cord disorders
* must provide value
Please describe (spinal cord disorder).
* must provide value
Please identify who in your family has had Huntington's Disease.
* must provide value
Please identify who in your family has had Gaucher's Disease.
* must provide value
Please identify who in your family has had Wilson's Disease.
* must provide value
Please identify who in your family has had Parkinson's Disease.
* must provide value
Please identify who in your family has had Alzheimer's Disease.
* must provide value
Please identify who in your family has had paraplegia.
* must provide value
Please identify who in your family has had Tourrett's Syndrome
* must provide value
Please identify who in your family has had other disease of the nervous sytem.
* must provide value
Mental
* must provide value
Please identify who in your family has had schizophrenia.
* must provide value
Please identify who in your family has had manic depressive or bipolar disease.
* must provide value
Please identify who in your family has had obsessive/compulsive disorder.
* must provide value
Please identify who in your family has committed suicide.
* must provide value
Please identify who in your family has had another mental disorder requiring hospitalization.
* must provide value
Muscular/Skeletal
* must provide value
Please identify who in your family has had muscular dystrophy.
* must provide value
Please identify who in your family has had another chronic muscle disease.
* must provide value
Please identify who in your family has had scoliosis.
* must provide value
Please identify who in your family has had loss of muscle coordination.
* must provide value
Please identify who in your family has had deformity of the spine.
* must provide value
Please identify who in your family has had lupus.
* must provide value
Please identify who in your family has had osteoporosis.
* must provide value
Please identify who in your family has had dwarfism.
* must provide value
Please identify who in your family has had arthritis.
* must provide value
Please identify who in your family has had gout.
* must provide value
Please identify who in your family has had myasthenia gravis.
* must provide value
Vision/Hearing/Smell
* must provide value
Please identify who in your family has had deafness before age 50.
* must provide value
Please identify who in your family has had deformity of the ear.
* must provide value
Please identify who in your family has had cataracts before age 50.
* must provide value
Please identify who in your family has had blindness.
* must provide value
Please identify who in your family has had glaucoma.
* must provide value
Please identify who in your family has had a retinoblastoma.
* must provide value
Please identify who in your family has had any other sight, sound, or smell disorder.
* must provide value
Please specify the other sight, sound, or smell disorder.
* must provide value
Please identify who in your family has had acne.
* must provide value
Please identify who in your family has had eczema.
* must provide value
Please identify who in your family has had skin cancer.
* must provide value
Please identify who in your family has had pigmentation disorder.
* must provide value
Please identify who in your family has had neurofibromatosis
* must provide value
Please identify who in your family has had infectious skin disorder.
* must provide value
Please identify who in your family has had another skin disorder.
* must provide value
Please specify the type of skin disorder.
* must provide value
Congenital Anomalies
* must provide value
Please identify who in your family has had cleft lip/palate.
* must provide value
Please identify who in your family has had hip problems.
* must provide value
Please identify who in your family has had club feet.
* must provide value
Please identify who in your family has had other congenital anomalies.
* must provide value
Please describe (other congenital anomalies).
* must provide value
Please identify who in your family has had Turner's Syndrome.
* must provide value
Please identify who in your family has had Klinefelter's Syndrome
* must provide value
Please identify who in your family has had Cri du Chat Syndrome.
* must provide value
Please identify who in your family has had Trisomy 18
* must provide value
Please identify who in your family has had Trisomy 13
* must provide value
Please identify who in your family has had Fragile X Syndrome.
* must provide value
Please identify who in your family has had cystic fibrosis.
* must provide value
Have you or a first-degree relative had alcoholism?
* must provide value
Yes
No
Don't Know
First-degree relatives: Mother, Father, Sister, or Brother
Please identify who in your family has had alcoholism.
Have you or a first-degree relative had drug abuse/misuse/addiction?
* must provide value
Yes
No
Don't Know
First-degree relatives: Mother, Father, Sister, or Brother
Please identify who in your family has had drug abuse/misuse/addiction.
Other
* must provide value
Please identify who in your family has had alcoholism.
* must provide value
Please identify who in your family has had drug abuse/misuse/addiction.
* must provide value
Please identify who in your family has had learning disabilities.
* must provide value
Please identify who in your family has had attention deficit disorder.
* must provide value
Please identify who in your family has had allergies (i.e. medication, food)
* must provide value
Please identify who in your family has had any other cancer not mentioned.
* must provide value
Please specify the other type of cancer.
* must provide value
Please identify who in your family has had any other condition not mentioned.
* must provide value
Please specify what condition.
* must provide value
Why do you want to be an ovum donor?
* must provide value
How would you describe your personality and character?
* must provide value
Briefly describe your philosophy of life.
* must provide value
What characteristics would be important to you for the recipient parents to possess?
* must provide value
Describe yourself as a child.
* must provide value
What was your family life like?
* must provide value
What is your earliest childhood memory?
* must provide value
Did you have any problems as a child?
* must provide value
Examples: health, learning, social, etc.
My favorite thing to do was:
* must provide value
At home I was expected to:
* must provide value
My parents taught me to value:
* must provide value
What I loved most about my father was:
* must provide value
What I loved most about my mother was:
* must provide value
My favorite relatives were:
* must provide value
I loved to visit:
* must provide value
In comparison to others, I was:
* must provide value
Describe yourself as a teenager.
* must provide value
Describe your achievements.
* must provide value
My favorite subject was:
* must provide value
My least favorite subject was:
* must provide value
My most important influence was:
* must provide value
In comparison to others, I was:
* must provide value
I traveled to:
* must provide value
I was talented as:
* must provide value
My ambition was to:
* must provide value
What religion were you born into?
* must provide value
How would you classify yourself:
* must provide value
Check all that apply
What religion do you currently practice?
* must provide value
If other, please explain.
* must provide value
Please describe your athletic talents.
* must provide value
What types of exercise or physical activities do you enjoy?
* must provide value
Have you ever participated in any organized sports? If so, please explain what you have participated in.
* must provide value
Do you have any musical talents?
* must provide value
Please describe any skills, interests, or talents you might have that have not been addressed.
* must provide value
What physical, artistic, or social abilities are you most proud of?
* must provide value
What have you achieved as an adult?
* must provide value
Submit
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