Egg donor
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Full name
Date of Birth
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Gender
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Street Address
City
State
Zip code
Phone
Email
Place of Birth
Are you adopted?
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Ethnicity
Height (Feet, Inches)
Weight (Kg)
What is your highest level of education?
What is your current occupation?
Have you donated your eggs previously?
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If yes, how many cycles?
Have you ever been told you are infertile?
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Is there any history of infertility in your family?
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Are there any known genetic diseases or conditions that run in your family?
Have you tested positive for chlamydia or gonorrhea in the past year?
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Have you ever used or injected any recreational drugs or illegal drugs? (Cocaine, marijuana, LSD, heroin, barbiturates, narcotics, opiates, amphetamines, hallucinations, tranquilizers, PCP, steroids, or others.)
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If yes, which drugs, and when were they last used?
Are you currently taking any medications?
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If yes, please provide the name and indication.
Have you ever been seen by a psychologist, psychiatrist, social worker, counselor, or any other medical health professional for any reason?
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If yes, for how long and what reason?
Have you lived cumulatively 5 years or more in Europe from 1980 until the present (this includes time spent in the United Kingdom from 1980-1996)?
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If yes, exactly where and for how long?
Have you had a tattoo or piercing in which sterile instruments were not used?
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