REPRODUCTIVE MEDICINE & SURGERY CENTER OF VIRGINIA

EGG DONOR APPLICATION
Phone Numbers:
okay to leave a detailed message?
Yes No
Yes No
Yes No
Required
Yes No
PERSONAL DESCRIPTION
( ex. French, Irish, African-American, Latino, Italian, Japanese, etc)
(medium, dark, light, fair, olive, freckles, etc )
(curly, straight, wavy, fine, thick, frizzy)
SOCIAL HISTORY
Tobacco use currently:
Yes No
If yes, how much?
If No,
have you smoked in the past?
How much?
How long ago did you quit?


Alcohol use:
Yes No
If yes, how much?
If No,
did you drink in the past?
How much?

Recreational/illegal drug use currently:
Yes No
If yes, what specifically and how frequently?
If No,
have you used in the past?
When was the last time?

Are you currently:
Single Married Living w/a partner
Does your significant other know of your interest in egg donation?
Yes No
If no, do you plan to tell your partner?
Yes No Undecided
How many times have you been pregnant?
never once twice three times or more
How many children do you have?
none one two three or more
Have you ever been convicted of a crime (other than a traffic violation)?
Yes No
If yes, how what specifically and when?
Have you ever been in jail/prison?
Yes No
If yes, for what specifically, when and length of stay?
PERSONAL ABILITIES/TALENTS:

How would you rank your ….

Personal Medical History
Do you have any medical conditions currently?
Yes No

Were you born with any handicaps or genetic conditions?
Yes No

Have you ever been hospitalized?
Yes No

Have you ever had surgery?
Yes No

Have you ever been diagnosed with any psychiatric illness?
Yes No

Have you ever been diagnosed with a STD (sexually transmitted disease)?
Yes No

Have you ever been pregnant before?
Yes No

Please describe the outcome of each pregnancy with dates, including any complications w/pregnancy, labor and delivery (ex. Elective termination, spontaneous miscarriage,premature birth, full term live birth, stillborn, etc.):

Have you ever received a blood transfusion?
Yes No

Have you ever been excluded from blood donation?
Yes No
If yes, when and where?
Have you ever donated your eggs elsewhere?
Yes No
If yes, when and where?
If yes, how many eggs were retrieved?
Family Medical History:
Relative
Mother
Father
Maternal grandmother
Maternal grandfather
Paternal Grandmother
Paternal Grandfather
Sibling 1
Sibling 2
Sibling 3
Aunt
Aunt
Uncle
Uncle
Alive?
Current age or age of death
Occupation
Years of completed education
Health problems:detailed description

First child:

Second child:

Third child:

Has anyone in your family had any of the following conditions?

Down’s Syndrome
Yes No
Mental retardation
Yes No
Seizure disorder
Yes No
Cleft lip and/or cleft palate
Yes No
Spina bifida (open spine)
Yes No
Hydrocephalus (water on the brain)
Yes No
Congenital heart defects
Yes No
Cystic fibrosis
Yes No
Mental illness (schizophrenia, bipolar, depression)
Yes No
Diabetes mellitus (onset prior to age 50)
Yes No
Club feet
Yes No
Congenital hip problems
Yes No
Thyroid disease
Yes No
Progressive kidney disease
Yes No
Skin disease
Yes No
Neurofibromatosis (lumps under the skin)
Yes No
Arthritis
Yes No
Alcoholism
Yes No
Colon cancer (before age 65)
Yes No
Hypertension
Yes No
Blood clotting disorder
Yes No
Ovarian cancer
Yes No
Huntington’s disease
Yes No
Marfan’s syndrome
Yes No
3 or more miscarriages or any stillbirths
Yes No
Blindness
Yes No
Deafness
Yes No
Cataracts
Yes No
Premature senility (before age 50)
Yes No
Muscle weakness/atrophy/dystrophy
Yes No
Light color patches on skin (tuberous sclerosis)
Yes No
Any other genetic conditions
Yes No

If yes is answered to any of the above questions, please explain:

Specific relation
Specific Condition
Age affected

How did you hear about our program? (Please circle one)
Newspaper Facebook Website Friend

Please attach a recent photo of yourself to the application (that you do not need returned….)

Thank you so much for taking the time to fill out this detailed application!

Please send to:
Reproductive Medicine & Surgery Center of Virginia ATTN: Stephanie Barrix, RN
595 Martha Jefferson Drive
Suite 390
Charlottesville, VA 22911