Physical Characteristics

Transcription

1 Donor ID# (to be assigned by staff) Please answer the following questions with as much detail and thoroughness as possible. Please mail the finished questionnaire back to the clinic. Please call us if you have any questions. We thank you for your interest in becoming a donor with our program, and look forward to working together in the future. Physical Characteristics Month / Year of Birth Occupation (do not indicate specific company) Please list known countries of origin, race and religion for the following family members: Country of Origin Race Religion Mother Maternal Grandmother Maternal Grandfather Father Paternal Grandmother Paternal Grandfather Your Height Your Weight Blood Type: A B AB O RH Factor: Positive Negative (Circle one for each of the following) Complexion: Fair Light Medium Dark Olive Lt. Olive Dk. Olive Hair Color: Lt. Blonde Blonde Dk. Blonde Lt. Brown Brown Dk. Brown Auburn Red Black Hair Texture: Wavy Curly Straight Eye Color: Gray Blue Hazel Green Brown Body Build: Small Medium Large Do you have freckles? No (Light) Only on my Face (Light) All over my body (Heavy) Only on My Face (Heavy) All over my body What happens when you are exposed to sun? Burn Easily Tan Easily Burn then Tan Don't Tan or Burn 1

2 What were your tanning habits from birth to 13 years old? Spray tan UV Bed Excessive exposure with several severe burns Moderate exposure with few minor burns Minimal exposure few to no burns What were your tanning habits from 13 to 20 years old? Spray tan UV Bed Excessive exposure with several severe bums Moderate exposure with few minor burns Minimal exposure few to no burns What are your current tanning habits? Spray tan UV Bed Excessive exposure with several severe burns Moderate exposure with few minor burns Minimal exposure few to no burns Are you predominantly: Right-Handed Left-Handed Ambidextrous Education High School: GPA: College/University: GPA: Universities Attended: Degree: Major: Post Graduate: GPA: Universities Attended: Degree: Area of Study: Personal Qualities: Please describe your personality and character: What are your interests, hobbies and talents? Do you have musical skills? 2

3 3 Do you have other artistic talents? Do you have athletic ability? Do you have leadership qualities? How have they been demonstrated in your life? Do you speak any other languages? Please list them. What are your future goals and aspirations? Please complete the following statements: I am proud of: What I value the most: I dislike: My best subjects in school are/ were:

4 My Favorites: Book: Movie: Type of Music: Musical Artist: Food: Color: Season: Holiday: Sport(s): TV Program: Childhood memory: Medical History: Do you have any ongoing or chronic medical conditions? YES NO If YES please explain: Please list any allergies you have or have had in the past: Environmental: Food: Medication: Braces from age to in order to correct Have you ever or do you currently wear eyeglasses? YES NO Have you ever or do you currently wear contact lenses? YES NO What is you current vision without corrective lenses? At what age did you begin wearing corrective lenses? Do you have a history of any of the following? Farsightedness YES NO Nearsightedness YES NO Stigmatism YES NO Double Vision YES NO Poor Night Vision YES NO Glaucoma YES NO Have you ever had chemotherapy and/or radiation? YES NO 4

5 Please list any medications you have taken in the past three months: NAME DOSE/FREQUENCY REASON Please indicate the frequency of use for the following substances: Alcohol Tobacco Marijuana Cocaine Other recreational Drugs Herbal Medications Have you ever had a surgical procedure? YES NO If YES: Please list type of procedure(s) and the date (MM/YY) of the surgery. Have you ever had difficulty with anesthesia? YES NO If YES: Please describe the problems you encountered. Please indicate if you have ever experienced any of the following: Abnormal PAP smear YES NO Did you have treatment if YES? Anemia. YES NO Amenorrhea (no menstrual period) YES NO Appendicitis YES NO Back problems (Surgery) YES NO Milky discharge from breast YES NO Chronic Headaches YES NO Endometriosis YES NO Hearing Issues YES NO Hirsutism (excess hair growth) YES NO irregular periods YES NO Kidney Infection YES NO Ovarian Cysts YES NO Pelvic Inflammatory Disease (PID) YES NO Rheumatic Fever YES NO Tubal Disease YES NO Tuberculosis YES NO Vaginitis (Trichomoniasis, yeast) YES NO # of episodes: Venereal Warts YES NO Visual Disturbances YES NO Rheumatic Fever YES NO 5

6 Fertility History: 1) Is there a family history of infertility? YES NO If yes, please indicate their familial relationship to you: 2) Is there a family history of hormonal disorders? YES NO If yes, please indicate their familial relationship to you and the type of disorder: 3) Have you been treated for infertility before? YES NO If yes, please indicate your physician: 4) What is your current method of birth control and how long have you used this method? 5) At what age was your first period? 6) Do you have a period every month? (21-35 days between periods) YES NO If NO: How often do you have a period? 7) Do you have spotting or bleeding between periods? YES NO 8) Have you ever been pregnant? (IF NO CONTINUE TO SEXUAL History) YES NO 9) Did you have trouble getting pregnant? YES NO 9A) How many times have you been pregnant? 9B) How many miscarriages have you had? 9C) How many pregnancies have you elected to terminate? 9D) How many live births have you had? 9E) How many of your children are living with you currently? 9G) Please list any birth defects, illnesses (other than usual childhood) for each child. If you have experienced the death of a child please tell us the date and cause of death. Please omit any names or birth dates. CHILD#1 CHILD#2 CHlLD#3 6

7 Sexual History: What is you sexual orientation? Heterosexual Homosexual Bisexual When was your last HIV Test? (MM/YY) (indicate if you've never been tested) What were the results of your latest HIV Test? Positive Negative Not Tested How many sexual partners have you had? How many in the last 12 months? Have you or any of your sexual partners ever had: You Your Partner Date Treatment Gonorrhea YES NO YES NO Syphilis YES NO YES NO Hepatitis A YES NO YES NO Hepatitis B YES NO YES NO Hepatitis C YES NO YES NO Chlamydia YES NO YES NO Genital Warts YES NO YES NO Genital Herpes YES NO YES NO Family History: 1) Are you adopted? YES NO 1A) Are you familiar with your biological family's YES NO medical history? (If YES, proceed to #3. If NO skip to next section) 2) Please complete your biological family's medical history. Are they Living? Age Medical Conditions (or Age at Death) and/or Cause of Death Mother YES NO Father YES NO Brother #1 YES NO Brother #2 YES NO Brother #3 YES NO Sister #1 YES NO Sister #2 YES NO Sister #3 YES NO Maternal Grandmother YES NO Paternal Grandmother YES NO Maternal Grandfather YES NO Paternal Grandfather YES NO 7

8 3) Please indicate your biological family's physical characteristics. Family Member Eye Color Hair Color Hair Texture Skin Tone Height Weight Mother Father Brother / Sister Brother / Sister Brother / Sister Brother / Sister Brother / Sister Maternal Grandmother Paternal Grandmother Maternal Grandfather Paternal Grandfather 4) Are there any know genetic diseases that run in your family? If so please list. 5) Please indicate below if you or any member of your biological family has had any of these medical conditions or diseases. In the space provided list the family member who is affected. Disease / Condition Individual(s) Affected Cleft Palate YES NO Cleft Lip YES NO Spina Bifida YES NO Congenital heart diseases YES NO Congenital hip dislocation YES NO Club Foot YES NO Other Birth Defects (please specify) Albinism YES NO Hemophilia YES NO Hemoglobin Disorder YES NO Hemochromatosis YES NO Hereditary Hypercholesterolemia YES NO _ Neurofibromatosis (von Recklinghausen's disease) Tuberous Sclerosis YES NO _ Asthma YES NO _ 8

9 Disease / Condition Individual(s) Affected Juvenile Diabetes YES NO _ Adult Onset Diabetes YES NO _ Epilepsy YES NO _ Hypertension YES NO _ Psychiatric Disorders YES NO _ Rheumatoid Arthritis YES NO _ Sever Eye refractive disorder YES NO _ Early coronary disease YES NO _ Cystic Fibrosis YES NO _ G6P Deficiency YES NO _ Thalassemia YES NO _ Sickle Cell Anemia YES NO _ Carrier for Sickle Cell Trait YES NO _ Tay-Sachs Disease YES NO _ Abnormal chromosome YES NO _ arrangement Mental Retardation YES NO _ Huntington's Chorea YES NO _ Congenital Adrenal Hyperplasia YES NO _ Fascioscapulohumeral Muscular Dystrophy YES NO _ Adult onset polycystic kidney disease YES NO _ Hypertropic Idiopathic Subaortic Stenosis (HISS) YES NO _ Amyotrophic Lateral Sclerosos (AMLS) YES NO _ Hereditary Spherocytosis YES NO _ Myotonic Dystrophy YES NO _ Duchene's Muscular Dystrophy YES NO _ Becker's Muscular Dystrophy YES NO _ Aquaductal Hydrocephalus YES NO _ Fragile X Syndrome YES NO _ 9

10 East Coast infertility and IVF Disease / Condition Individual(s) Affected Retinitis Pigmentosa YES NO _ Multiple Ployposis of the colon YES NO _ Marfan Syndrome YES NO _ Retinoblastoma YES NO _ Alport's Disease YES NO _ Cataracts before age 40 YES NO _ Deafness before age 60 YES NO _ Cancer YES NO _ Philosophy about egg donation: Would you be willing to meet the child / children in the future if they wanted to know about their genetic roots? Are you willing to contact the fertility center if you become aware of any genetic conditions in your family? If you could pass a message to the recipient what would it be? 10

11 East Coast infertility and IVF Demographic Information Please complete the following demographic information. This information will not be disclosed to any potential recipients. First Name Last Name Contact Number #1 Contact Number #2 Address Date of Birth (MM/DD/YYYY) Age at Application Marital Status M S D W Social Security # Insurance Company By signing below, I verify that the information provided in this document is truthful and accurate to the best of my knowledge. I have answered honestly to all questions including my age, medical, sexual, and family history. Signature _ Date Please attach a picture(s) of yourself as an INFANT or TODDLER. (Originals will not be returned - please submit color or B/W copies) IF YOU HAVE ANY QUESTIONS PLEASE CONTACT OUR OFFICE (732) Donor ID (for office use only) 11