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Initial Oocyte Donor Screening

First Name Last Name U.S. Citizen Yes No
Age DOB Email Address
Marital Status Single Married Separated Divorced Other
Phone Number OK to leave a message? Yes No
Cell Number OK to leave a message? Yes No

Health Information

Height Weight BMI Ethnicity
Do you smoke? Yes No If yes, how often
Do you drink alcoholic beverages? Yes No If yes, how often
Do you have any medical problems? Yes No
If yes, please explain
Do you have a history of depression/psychiatric issues? Yes No
If yes, please explain
Have you ever been pregnant before? Yes No
How many children do you have?
Are you currently pregnant or breastfeeding? Yes No
Are you on any medications? Yes No
If yes, please explain
Do you have irregular periods? Yes No
How many abortions have you had?
How many miscarriages have you had?
Have you taken any medications in the past 5 years not prescribed by a physician? Yes No
If yes, please explain
Have you ever been an egg donor? Yes No If yes, how many times
Are you adopted? Yes No If yes, do you know your biological parents? Yes No
Do you have a family history of birth defects? Yes No
If yes, please explain
Have you ever been diagnosed with a sexually transmitted disease? Yes No
If yes, name of disease and any treatment
Have you had any piercings/tattoos in the past 12 months? Yes No
Have you ever been denied donating blood or tissue? Yes No I don't know
If yes, please explain
Have you been exposed to known or suspected HIV, Hepatitis B or Hepatitis C? Yes No
Have you had a smallpox vaccination in the past 8 weeks? Yes No
Are you willing to give yourself medications by injections or have someone you know give them to you? Yes No
Do you have a flexible schedule? Yes No
Are you able to provide 4-6 photos from birth to present? Yes No
What county do you live in?
Do you have reliable transportation? Yes No
How did you hear about our program?
Patient Signature