First Name:
Last Name:
Date of Birth:
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1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940
* (mm/dd/yyyy)
Address 1:
Address 2:
City:
State:
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AK AL AR AS AZ CA CO CT DC DE FL GA GU HI IA ID IL IN KS KY LA MA MD ME MI MN MO MP MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR RI SC SD TN TX UT VA VI VT WA WI WV WY
Zip:
Home Phone:
Daytime Phone:
email:
Alternate Phone:
I heard about egg donation through:
Name:
Name:
Where:
If accepted as an egg donor I would be available to serve beginning:
I would be most interested in donating eggs at:
Select City
CHR Chicago, Illinois
CHR New York City,New York
Marital Status:
Place of Birth:
City:
State/Province:
Country:
Ethnicity (check all that apply):
Enter Other:
Please select your ancestry and provide the percentage. You can add up to 8 ancestries.
Select Ancestry
Aboriginal African Albanian Arab Argentinean Armenian Australian Austrian Baltic Bengali Bosnian Brazilian Chilean Chinese Czechoslovakian Dominican Dutch Egyptian English Ecuadorean Eskimo French Guyanese Georgian German Guatemalan Haitian Hawaiian Hungarian Icelandic Indian Irish Israeli Italian Japanese Korean Lebanese Mexican Mongolian Native Am American Norwegian Pacific Islander Pakistani Persian Peruvian Philippine Polish Portuguese Puerto Rican Romanian Russian Scottish Serbian Sri Lankan Swedish Swiss Thai Trinidadian Turkish Ukrainian Uzbekistanian Vietnamese Venezuelan Welsh Other Greek Bolivian
Select Ancestry
Aboriginal African Albanian Arab Argentinean Armenian Australian Austrian Baltic Bengali Bosnian Brazilian Chilean Chinese Czechoslovakian Dominican Dutch Egyptian English Ecuadorean Eskimo French Guyanese Georgian German Guatemalan Haitian Hawaiian Hungarian Icelandic Indian Irish Israeli Italian Japanese Korean Lebanese Mexican Mongolian Native Am American Norwegian Pacific Islander Pakistani Persian Peruvian Philippine Polish Portuguese Puerto Rican Romanian Russian Scottish Serbian Sri Lankan Swedish Swiss Thai Trinidadian Turkish Ukrainian Uzbekistanian Vietnamese Venezuelan Welsh Other Greek Bolivian
Select Ancestry
Aboriginal African Albanian Arab Argentinean Armenian Australian Austrian Baltic Bengali Bosnian Brazilian Chilean Chinese Czechoslovakian Dominican Dutch Egyptian English Ecuadorean Eskimo French Guyanese Georgian German Guatemalan Haitian Hawaiian Hungarian Icelandic Indian Irish Israeli Italian Japanese Korean Lebanese Mexican Mongolian Native Am American Norwegian Pacific Islander Pakistani Persian Peruvian Philippine Polish Portuguese Puerto Rican Romanian Russian Scottish Serbian Sri Lankan Swedish Swiss Thai Trinidadian Turkish Ukrainian Uzbekistanian Vietnamese Venezuelan Welsh Other Greek Bolivian
Select Ancestry
Aboriginal African Albanian Arab Argentinean Armenian Australian Austrian Baltic Bengali Bosnian Brazilian Chilean Chinese Czechoslovakian Dominican Dutch Egyptian English Ecuadorean Eskimo French Guyanese Georgian German Guatemalan Haitian Hawaiian Hungarian Icelandic Indian Irish Israeli Italian Japanese Korean Lebanese Mexican Mongolian Native Am American Norwegian Pacific Islander Pakistani Persian Peruvian Philippine Polish Portuguese Puerto Rican Romanian Russian Scottish Serbian Sri Lankan Swedish Swiss Thai Trinidadian Turkish Ukrainian Uzbekistanian Vietnamese Venezuelan Welsh Other Greek Bolivian
Select Ancestry
Aboriginal African Albanian Arab Argentinean Armenian Australian Austrian Baltic Bengali Bosnian Brazilian Chilean Chinese Czechoslovakian Dominican Dutch Egyptian English Ecuadorean Eskimo French Guyanese Georgian German Guatemalan Haitian Hawaiian Hungarian Icelandic Indian Irish Israeli Italian Japanese Korean Lebanese Mexican Mongolian Native Am American Norwegian Pacific Islander Pakistani Persian Peruvian Philippine Polish Portuguese Puerto Rican Romanian Russian Scottish Serbian Sri Lankan Swedish Swiss Thai Trinidadian Turkish Ukrainian Uzbekistanian Vietnamese Venezuelan Welsh Other Greek Bolivian
Select Ancestry
Aboriginal African Albanian Arab Argentinean Armenian Australian Austrian Baltic Bengali Bosnian Brazilian Chilean Chinese Czechoslovakian Dominican Dutch Egyptian English Ecuadorean Eskimo French Guyanese Georgian German Guatemalan Haitian Hawaiian Hungarian Icelandic Indian Irish Israeli Italian Japanese Korean Lebanese Mexican Mongolian Native Am American Norwegian Pacific Islander Pakistani Persian Peruvian Philippine Polish Portuguese Puerto Rican Romanian Russian Scottish Serbian Sri Lankan Swedish Swiss Thai Trinidadian Turkish Ukrainian Uzbekistanian Vietnamese Venezuelan Welsh Other Greek Bolivian
Select Ancestry
Aboriginal African Albanian Arab Argentinean Armenian Australian Austrian Baltic Bengali Bosnian Brazilian Chilean Chinese Czechoslovakian Dominican Dutch Egyptian English Ecuadorean Eskimo French Guyanese Georgian German Guatemalan Haitian Hawaiian Hungarian Icelandic Indian Irish Israeli Italian Japanese Korean Lebanese Mexican Mongolian Native Am American Norwegian Pacific Islander Pakistani Persian Peruvian Philippine Polish Portuguese Puerto Rican Romanian Russian Scottish Serbian Sri Lankan Swedish Swiss Thai Trinidadian Turkish Ukrainian Uzbekistanian Vietnamese Venezuelan Welsh Other Greek Bolivian
Select Ancestry
Aboriginal African Albanian Arab Argentinean Armenian Australian Austrian Baltic Bengali Bosnian Brazilian Chilean Chinese Czechoslovakian Dominican Dutch Egyptian English Ecuadorean Eskimo French Guyanese Georgian German Guatemalan Haitian Hawaiian Hungarian Icelandic Indian Irish Israeli Italian Japanese Korean Lebanese Mexican Mongolian Native Am American Norwegian Pacific Islander Pakistani Persian Peruvian Philippine Polish Portuguese Puerto Rican Romanian Russian Scottish Serbian Sri Lankan Swedish Swiss Thai Trinidadian Turkish Ukrainian Uzbekistanian Vietnamese Venezuelan Welsh Other Greek Bolivian
Religion Born into:
Personal Characteristics
Height:
Select Height
5'
5' 1''
5' 2''
5' 3''
5' 4''
5' 5''
5' 6''
5' 7''
5' 8''
5' 9''
5' 10''
5' 11''
6'
6' 1''
6' 2''
6' 3''
6' 4''
6' 5''
6' 6''
6' 6+'
Weight:
Enter Weight:
Build:
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X-Small
Small
Medium
Large
Eye Color:
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Blue
Black
Brown
Green
Hazel
Other
Natural Hair Color:
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Auburn
Ashe Blonde
Strawberry Blonde
Blonde
Light Brown
Dark Brown
Black
Red
Type of Hair (check all that apply):
Do you wear corrective lenses:
Are you predominantly:
Skin Tone:
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Fair
Medium
Olive
Dark
Freckles:
Select Freckles
None
Few
Numerous
Additional Characteristics (check all that apply):
Education/Work/Interests
Educational Background (check all that apply):
Degree Achieved:
Major Area of Study:
Degree Achieved:
Major Area of Study:
Degree Achieved:
Major Area of Study:
S.A.T. Scores:
Total Score:
Verbal:
Math:
Other Placement Scores:
LSAT:
MCAT:
GRE:
Other:
Work/Occupation History
Enter Occupation:
What kind of work have you done in the past?
What kind of work is most appealing to you?
Personal Preferences/Abilities:
Are you skilled mechanically or technically?
How would you rate your Abilities in Mathematics:
Literary Skills:
Scientific/Research Ability:
Athletic Abilities
Do you have a favorite sport?
Please list your favorite sports:
How would you rate your Musical Skills/Ability:
Artistic Talents:
Other than English, what languages do you speak? (check all that apply):
Do you have any special talents or hobbies?
If yes, please list your talents or hobbies:
How would you describe your personality?
What is your ultimate ambition in life?
Social History
Tobacco (Check all that currently apply):
Alcohol
Drug usage:
Enter usages:
Have you ever used injectable drugs?
If yes, when did you last use injectable drugs?
Sexual Behavior:
The Law (check all that apply):
If yes, explain the type of legal trouble you have had:
Crimes:
What was the crime you were convicted of perpetrating?
Psychological History:
Have you ever sought counseling for depression or emotional problems?
Have you ever taken antidepressants for more than three months at a time?
Have you ever been diagnosed as having any of the following (please check all that apply)
Personal Health History:
Do you have any allergies that you're aware of?
If yes, please indicate what you are allergic to:
Are you allergic to any medications?
If yes, please tell us what medication you're allergic to:
Were you or any of your relatives born with genetic disorders that led to hearing impairment?
Do you have any dietary restrictions?
If yes, what are your dietary restrictions, and for what reason?
Do you take any supplemental vitamins or herbal remedies on a continual basis?
If yes, please list what vitamins or herbal remedies you are taking:
Do you take any prescription or over the counter medication on a regular or continual basis?
If yes, please list what medication you are currently taking:
Do you exercise regularly?
Have you had any surgeries in the past?
If yes, please indicate what surgeries you have had:
Have you ever had an adverse reaction to general anesthetics?
If yes, please indicate what happened, and the severity of the response:
Have you ever been hospitalized for anything other than the above listed surgeries?
If yes, please tell us why you were hospitalized:
Menstrual History:
(please answer the following questions about your menstrual cycle)
How old were you when you first began to menstruate:
How many days are there (usually) between one period to the next?
How many days do your periods usually last?
Do you ever experience mid-cycle bleeding?
Would you describe your menstrual cycle as:
In general, how heavy is your menstrual flow?
Have you ever taken, or are you currently taking oral contraceptives?
If yes, what brand and for how long?
What methods of contraceptive have you used? Please list:
Sexual Activity/History:
(please answer the following questions about your sexual history)
How many sexual partners have you had intercourse with in the past year?
Have you been with a sexual partner that is a known user of drugs?
Have you had intercourse with a bisexual or homosexual partner?
Have you had intercourse without the use of a condom in the last year?
Have any of your past or present sexual partners shown evidence of having HIV infection?
Have you ever been with a sexual partner who tested positive for a sexually transmitted disease?
If you answered yes to any of the above questions, please explain in full detail:
Pregnancy History:
Have you ever been pregnant?
If yes, how many times have you been pregnant?
Have you ever carried a pregnancy to term?
If yes, were there any complications with gestation or delivery?
If yes, what were the complications?
How many times have you given birth?
Has every delivery resulted in a live birth?
Have you ever been told in the past, that you have had any of the following? (check all that apply):
Sepsis West Nile Virus (You or any relative)
Vaccinia Creutzfeld-Jakob disease (CJD)
Do you have an occupation with risk of exposure to radiation or other chemicals that could be harmful to your health?
If yes, please explain what chemicals you are or have been exposed to:
Have you had a Pap Smear within the past 6 months?
Was result of your Pap Smear within normal limits?
What's your blood type:
Please Choose
A positive
A negative
AB positive
AB negative
B positive
B negative
O positive
O negative
Not sure
Have you received a blood transfusion within the past six months?
Have you ever received a blood transfusion or other blood products at any time in your life?
If yes, when did this happen?
Are you a current or former U.S. military or civilian military employee (or dependent), who resided on a military base in Germany, Belgium, or The Netherlands for 6 months or more between 1980-1990?
Yes
Are you a current or former U.S. military or civilian military employee (or dependent), who resided on a military base in Greece, Turkey, Spain, Portugal, or Italy for 6 months or more between 1980-1996?
No
Have you ever spent 5 or more cumulative years in Europe?
Yes
No
Did you spend 3 or more cumulative months in the U.K. between 1980-1996?
Yes
No
Have you received any blood transfusions or transfusions of blood products in the U.K. or France?
Yes
No
Have you or your sexual partner lived in Cameroon, Central African Republic, Chad, Congo, Equatorial Guinea, Gabon, Niger, or Nigeria since 1977?
Yes
No
Have you ever received blood transfusions or other blood products in any of the African countries listed above?
Yes
No
Ever been diagnosed with dementia, or other diseases of the central nervous system?
Yes
No
Ever received a human pituitary-derived growth hormone?
Yes
No
Ever had a non-synthetic dura mater transplant?
Yes
No
Ever received any transplantation of living cells (xenotransplant), or had intimate contact with any xenotransplant recipient?
Yes
No
Have you acquired a tattoo within the last year?
If yes, when did you get your newest tattoo?
Have you ever had an animal bite or rabies?
Have you ever received blood products or clotting factors for abnormal bleeding?
Have you ever been excluded from blood donation?
If yes, please explain when and why:
Have you ever received Pituitary derived growth hormone?
Family History
Relative Alive? Present age or age of death Height Weight Hair Color Eye Color Any Medical Problems Occupation Birth Place
Mother
Select Height
<5'
5' 1''
5' 2''
5' 3''
5' 4''
5' 5''
5' 6''
5' 7''
5' 8''
5' 9''
5' 10''
5' 11''
6'
6' 1''
6' 2''
6' 3''
6' 4''
6' 5''
6' 6''
>6' 6''
Select Hair Color
Auburn
Ashe Blonde
Strawberry Blonde
Blonde
Light Brown
Dark Brown
Black
Red
Select Eye Color
Blue
Black
Brown
Green
Hazel
Other
Maternal Grandmother
Select Height
