Preliminary Donor Application

1Demographics
2Medical History

First Name

Last Name

Phone

Birthdate

Sun Mon Tue Wed Thu Fri Sat

Country

Street Address

City

State

Zip Code

Height

Weight (lbs)

lbs

Do you live within 50 miles of Bellevue, WA?

Do you have reliable transportation?

Does your daily routine or schedule allow you (if selected to be a egg donor) to come to the office daily for a period of 8-10 days in row for AM monitoring/injection appointments?

Highest level of education received?

Are you currently enrolled in school?

Have you ever been convicted of a felony?

Have you ever been diagnosed with an eating disorder, such as anorexia or bulimia?

Have you ever used self-induced vomiting to control overeating?

Do you have a monthly period?

Date of last menstrual period

Sun Mon Tue Wed Thu Fri Sat

Do you currently smoke?

Do you currently drink?

Ethnicity

Ethnicity #1

Do you currently have any medical problems?

Do you have a history of medical conditions/problems?

Yes

Does anyone in your family have a history of medical conditions/problems?

Do you have a history of mental disorders?

Have you ever been hospitalized for psychiatric reasons?

Does anyone in your family have a history of mental disorders?

Have you ever had any of the following:

Chlamydia

Gonorrhea

Hepatitis B

Hepatitis C

HIV

None of the above

Are you currently on birth control?

Have you donated your eggs in the past?

Have you ever been pregnant before?

Have you ever undergone fertility treatment for any reason?

Have you ever been treated for endometriosis?

How did you hear about our egg donor program?