Donor Application Form

1. Are you eligible to work in the United States?

Please select... Yes No

2. Are you a US citizen or permanent resident?

Please select... Yes No

3. What is your FIRST name?

4. What is your LAST name?

5. What is your email address?

6. What is your mailing address?

Street City State/Province Zip/Postal Code Country

7. How far away from our practice do you live?

Please select... < 30 minutes 31 to 60 min. 1-2 hours 2-3 hours over 3 hours

8. What is the primary phone number (include area code) to use for contact and leaving messages?

Ext.

9. What is your date of birth?

10. What is your height?

Please select... 4'8" 4'9" 4'10" 4'11" 5'0" 5'1" 5'2" 5'3" 5'4" 5'5" 5'6" 5'7" 5'8" 5'9" 5'10" 5'11" 6'0" 6'1" 6'2" 6'3" 6'4" 6'5" 6'6" 6'7" 6'8"+

11. What is your weight?

Please select... 90 95 100 105 110 115 120 125 130 135 140 145 150 155 160 165 170 175 180 185 190 195 200 205 210 215 220 225 230 235 240 245 250 255 260

12. What is your eye color?

Please select... Blue Brown (light) Brown Brown (dark) Green Hazel

13. What is your natural hair color?

Please select... Black Blonde (light) Blonde (medium) Blonde (dark) Brown (light) Brown (medium) Brown (dark) Red Auburn

14. What race would you most likely be affiliated?

Please select... African American American Indian Caucasion Asian Polynesian Hispanic Indian Jewish Mediterranean Other(explain)

Other race or self-description of race

15. Are you adopted?

Please select... Yes - I know my biological information Yes - I don't know my biological information No

16. What is the ethnic origin of your mother? (e.g. French, Irish)

17. What is the ethnic origin of your father? (e.g. French, Irish)

18. How many years of college did you complete?

Please select... 0 1 2 3 4 5 6 7+

19. What is your current occupation?

20. Do you have medical insurance?

Please select... Yes No

21. Have you been vaccinated in the past 12 months?

Please select... Yes No

If yes, what were you vaccinated for?

22. Are you currently under a physicians care for any reason?

Please select... Yes No

If yes, please explain.

23. List all medications that you have taken in the proceeding 12 months (prescription). Enter "N/A" in the first box if you have not taken medications.

Rx Medications Medication How Often Reason 1 2 3 4 5 6 7

24. List all current over-the-counter medications (including hormones, vitamins, aspirin, antacids, laxatives, herbal & sports supplements, performance-enhancing supplements including steroids, etc.). Enter "N/A" in the first box if you have not taken any OTC medications.

OTC Medications Medication How Often Reason 1 2 3 4 5 6 7

25. Do you or your family or relatives have birth defects, genetic diseases, or serious medical problems?

Please select... Yes No

If yes, explanation required.

26. Do you or your family or relatives have any history of any significant emotional or psychological problems (depression, bipolar, ADD, etc)?

Please select... Yes No

If yes, explanation required.

27. How long is your monthly menstrual cycle (first day of one period to first day of the next)? (In days)

Please select... <15 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41+

28. Have you ever had trouble conceiving? If yes, when and why?

Please select... Yes No I haven't tried

If yes, when and was the cause identified?

29. How many pregnancies have you had?

Please select... 0 1 2 3 4 5 6 7 8 9 10+

30. To how many children have you given birth?

Please select... 0 1 2 3 4 5 6 7 8 9 10+

31. How many cigarettes do you smoke per day?

Please select... 0 1 2 3 4 5 6 7 8 9 10+

32. When is the last time you had marijuana?

Please select... Never 0 to 3 months ago 6 months ago 9 months ago Over 1 year ago Over 2 years ago Over 3 years ago

33. When is the last time you used other recreational or illicit drugs (cocaine, LSD, heroin, barbiturates, narcotics, opiates, amphetamines, hallucinogens, tranquilizers, PCP, steroids, or etc.)?

Please select... Never 0 to 3 months ago 6 months ago 9 months ago Over 1 year ago Over 2 years ago Over 3 years ago

If yes, which one(s)?

34. Have you ever been convicted of a felony?

Please select... Yes No

If yes, explanation required.

35. Does anyone in your family have a family history of alcoholism, drug use, abuse, or addiction?

Please select... Yes No

If yes, please list who and additional details (such as currently struggling, in therapy, sober for 2 years, etc)

36. Have you applied or been screened to be an egg donor before?

Please select... Yes No

If yes, provide the name and location of the donor program(s).

37. How many times have you donated?

Please select... 0 1 2 3 4 5 6 7 8 9 10+

38. Are you currently enrolled as an egg donor in another program?

Please select... Yes No

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

40. Please add additional comments or questions:

41. Are you currently pregnant or trying to get pregnant?

Please select... Yes No

42. Are you currently breastfeeding?

Please select... Yes No

43. What resources did you use and/or impacted your decision to apply?