Please tick ( ) and complete ALL questions. YOU YOUR PARTNER Full name Forename Surname Forename Surname Date of birth day / month / year day / month / year Address Height : Weight: Ethnicity Home Tel: Work Tel: Cell 1: Cell 2: Email: @ Your marital status Single Married Divorced Other How would you like us to contact you? Email Post Phone Have you been an egg donor before? [ ] Yes [ ] No If yes, where? Are you currently in a sexual relationship? If yes, duration of relationship with partner: [ ] Yes [ ] No Occupation: Did you go to college? How many years did you complete in high school? If yes, please give details How many times have you been pregnant? Please give details of all your pregnancies: Livebirth-stillbirth-miscarriage-termination Year Details (length of pregnancy, sex, type of birth etc)
Please describe your family members ethnic and general appearance characteristics. Please take time to complete this in as much detail as you can as this is very IMPORTANT for the clinic Relation Eye Color Hair Color Height Weight Ethnic Origin Age L/D Cause of Death Mother Father Maternal Grandmother Maternal Grandfather Relation Eye Color Hair Color Height Weight Ethnic Origin Age L/D Cause of Death Paternal Grandmother Paternal Grandfather Your Siblings Eye Color Hair Color Height Weight Ethnic Origin Age L/D Cause of Death Have you ever had fertility treatment? [ ] No [ ] Yes please give details below How regular are your periods? Do you suffer with any of the following tick all that apply to you) [ ] Always regular [ ] Usually regular (sometimes 1-3 days late or early) [ ] Mostly regular (sometimes skip a few weeks or a month) [ ] Not regular (often skip 1-3 months) [ ] Completely irregular 9no pattern at all) [ ] I have had no periods for over a year [ ] Moderate period pain [ ] Severe period pain [ ] Pain with sexual intercourse0 [ ] Bleeding after sexual intercourse [ ] Bleeding at times other than your period [ ] Vaginal discharge that is not normal [ ] Discharge from the breast
Do you have any medical problems? [ ] No [ ] Yes - please give details below Have you had any surgery? [ ] No [ ] Yes - please give details below Have you had any hospitalizations not mentioned above? Have you had major radiation or X-ray exposure? If yes, please give details: [ ] No [ ] Yes Do you smoke? Do you have a police record? [ ] No [ ] Yes [ ] No [ ] Yes - please give details below Do you take any drugs or medications? [ ] No [ ] Yes - please give details below Name of Medication Dosage Reason Prescribed 1. 2. 3. 4. 5. Have you sought counseling in the past for emotional problems? Have you ever used any of the following? [ ] No [ ] Yes Cocaine [ ] No [ ] Yes Marijuana or weed [ ] No [ ] Yes Heroin [ ] No [ ] Yes Other illegal drugs YOUR CHARACTERISTICS How would you describe your appearance and features? Body Frame: Small Medium Large Natural Hair Color: Lt. Brown Brown Dark Brown Black Blonde Premature Gray Auburn Red
Hair texture (natural state): Afro Thick and Curly Thin and curly Light wave only Straight Eye Color: Blue Gray Green Hazel Brown Black Skin Tone: Fair/white Light brown Medium brown Dark brown Ebony/black [ ] Right Handed [ ] Left Handed [ ] Ambidextrous (can use both) Vision (without corrective lenses): Poor Fair Good Excellent Hearing (without corrective device): Poor Fair Good Excellent Diet: Vegetarian Non-Vegetarian If you or anyone in your family has had any of the following conditions, check yes and describe below: Condition YES NO Condition YES NO Down s syndrome Skin Disease: Eczema/ Psoriasis Mental Retardation Mental problems Known Chromosomal Disorder Cystic Fibrosis Seizure Disorder / epilepsy Hemophilia Muscular Dystrophy Arthritis (before age 50) Multiple Sclerosis Sickle Cell Anemia Premature Senility(Before age 50) Early Heart Attack(before age 50) Deafness (before age 50) Early stroke (before age 50) Blindness Alcoholism Cataracts (before age 40) Asthma Schizophrenia or Manic Depression High Blood Pressure Serious Birth Defects Cancer: type and location Cleft Lip and/or Cleft Palate B-Thalassemia Open Spine or Water on the Brain A-Thalassemia Congenital Heart Problems Diabetes Mellitus Two or More Miscarriages or Thyroid Disease Stillborns Polycystic Kidney Disease Kidney disease If you answered YES to any of the above questions, please answer the following: Specific Relation or Family Member Condition Age of onset
If you or anyone in your family had any of the following conditions, check yes and describe below: Liver Disease Appendicitis Color Blindness Sarcoidosis Tuberculosis Ulcers Alzheimer s Gout Dwarfism Wilson s Disease Goiter Emphysema Skin Cancer: Melanoma Kidney/ Gall Stone YES NO YES NO Lung Disease Crohn s Disease Huntington s Chorea Lupus Hepatitis A, B, or C Colitis Osteoporosis Cerebral Palsy Migraines Glaucoma Leukemia Dyslexia Hodgkin s Disease If you answered YES to any of the above questions, please answer the following: Specific Relation or Family Member Condition Age of onset Have you ever donated blood or any blood products? [ ] No [ ] Yes Have you ever had yellow jaundice, liver disease, and hepatitis? [ ] No [ ] Yes Have you ever had a positive test for hepatitis? [ ] No [ ] Yes Have you ever had radiation or chemotherapy? [ ] No [ ] Yes Have you had a major illness or surgery in the last 12 months? [ ] No [ ] Yes Have you ever had a blood transfusion? [ ] No [ ] Yes Have you had an organ or tissue transplant? [ ] No [ ] Yes Have you had a positive test for syphilis? [ ] No [ ] Yes Have you been treated for syphilis or gonorrhea? [ ] No [ ] Yes Have you had sex with anyone who has taken money for sex? [ ] No [ ] Yes Since 1977, have you taken money or drugs for sex? [ ] No [ ] Yes Have you had sex with a male who has had sex with another male? [ ] No [ ] Yes
What do you hope to achieve by volunteering in the egg donor program (emotionally, financially, etc.)? What message would you like passed on the recipient of you eggs/their offspring? What helped you decide to become an egg donor? How would you describe yourself? Please include a description of your personality and temperament: Describe your philosophy of life: YOUR CHILDHOOD: Describe yourself as a child (personality, health, happiness, etc.).
What was it like growing up in your family? What religion did you belong to as a child? What was your earliest memory as a child? What problems did you have as a child (health, allergies, learning, social, etc.)? WHEN I WAS A CHILD: My favorite thing to do was: My parents taught me to value What I loved most about my father was: What I loved most about my mother was: ADULTHOOD: Religion: How religious are you now? Very Moderately Not at all What religion are you currently: Activities: How athletic are you? Very Average Not Athletic Do you exercise? Regularly Occasionally Not at all What types of exercise or physical activity do you enjoy? Do you have musical ability? What other skills or talents do you have (painting, writing, reading, ability at games, crossword puzzles, handicraft, etc)? Please describe in detail.
Describe any special interests you have (Girl Scout leader, fund raiser, pet owner, volunteer activities, etc.): What physical, artistic, intellectual, or social abilities do you have? What have been your achievements as an adult? CONSENT FORM I,, have completed the above questions honestly and to the best of my knowledge and ability. I understand that this information will be used and relied on by Trinidad IVF and Fertility Centre Limited and by its patients. I have not knowingly nor intentionally given false or misleading information. I understand that knowingly or intentionally providing false information will not only be a cause for my disqualification as an egg donor, but will also allow the Trinidad IVF and Fertility Centre Limited to bring lawsuit for a recipient in order to recover damages they might have incurred. FAMILY NAMES: Your mother s name and DOB: Any other names by which she is known: Current address: Your father s name and DOB: Any other names by which he is known: Current address: DATE: SIGNATURE: PRINT NAME WTINESS SIGNATURE & NAME: OFFICE USE ONLY This form has been checked by me and in my opinion this candidate has passed the initial screening questionnaire, signed (DOCTOR): DATE: