Date of birth:
Are you adopted?
Recent weight loss/gain:
If yes how many lbs:
What was your weight at age 21?
Hair Color as child:
Baldness in Family:
Body and Facial Features:
Vision Quality (without corrective lenses):
Hearing (without corrective aids):
Any periodontal or orthodontic work?
Ethnic Origin (list countries):
Religion Born Into:
Number of children?
How long have you been at your current occupation:
High School G.P.A:
Any learning disabilities or weaknesses in school?
If yes, please describe:
Academic Strengths (i.e. math, reading):
What have you accomplished so far?
What are some awards/achievements you are proud of?
Artistic Abilities (i.e. musical, painting):
Favorite subject in school:
Favorite Types of Exercise:
How would you describe yourself?
What would you say is your best personality trait?
What is your most unique quality?
Describe yourself as a child:
What did your parents teach you to value?
Is there a person alive or dead whom you admire and why?
Who was the most important influence on you and why?
Why do you want to be an egg donor?
What message would you like to pass on to the recipient(s) of your eggs?
Are you open to donating to a single Male?
Are you open to donating to a single Female?
Are you open to donating to a gay person or gay couple?
PGF=Paternal Grandfather PGM=Paternal Grandmother
MGF=Maternal Grandfather MGM=Maternal Grandmother
Age (time of death):
Cause of Death:
Age (time of death):
Sibling 1 (M/F)
Mother's level of education:
Describe your mother's personality:
Father's level of education:
Describe your father's personality:
Paternal Grandfather's Occupation:
Paternal Grandfather's level of education:
Describe your paternal grandfather's personality:
Paternal Grandmother's Occupation:
Paternal Grandmother’s level of education:
Describe your paternal grandmother’s personality:
Maternal Grandfather’s Occupation:
Maternal Grandfather’s level of education:
Describe your maternal grandfather’s personality:
Maternal Grandmother’s Occupation:
Maternal Grandmother’s level of education:
Describe your maternal grandmother’s personality:
Sibling 1 Occupation:
Sibling 1 level of education:
Describe your sibling 1 personality:
Number of children?
Sex of children?
Sibling 2 Occupation:
Sibling 2 level of education:
Describe your sibling 2 personality:
Sex of children?
Sibling 3 Occupation:
Sibling 3 level of education:
Describe your sibling 3 personality:
Sibling 4 Occupation:
Sibling 4 level of education:
Describe your sibling 4 personality:
Child 1 personality and special skills:
Child 2 personality and special skills:
How many blood siblings are in your immediate family (including yourself and half siblings)?
Number of Brothers
Number of Sisters
Number of Maternal Uncles
Number of Maternal Aunts
Number of Paternal Uncles
Number of Paternal Aunts
Any brothers or sisters that died in infancy or childhood?
If yes, what was the cause?
Do any members of your family have a history of learning disabilities or autism?
If yes, please explain:
Race: Check all that apply for your ancestors
Have you or anyone in your family ever been tested positive as a carrier or had any of the following diseases?
Is there anything else we should know about your family?
Personal and Family Medical History
(Please include yourself, mother, father, siblings, grandparents, aunts, uncles, and cousins)
Current allergies (food, pollen, bee stings, medications, etc.):
Childhood allergies you have outgrown:
Medical illnesses, such as asthma, diabetes, seizure disorders, etc.?
Do you have astigmatism (blurred vision due to an irregularity in the curvature of the cornea)?
If yes, age diagnosed
Do you have any dietary restrictions?
(including breast, colon or intestinal, lung, ovarian or uterine, prostate or testicular, skin, stomach, thyroid, blood (e.g. leukemia), other)
(including stroke, heart attack, heart disease, hardening of arteries, high blood pressure, high cholesterol level):
(including anemia, sickle-cell anemia, hemophilia or other bleeding problem, blood clots or strokes, leukemia, immune deficiency, lymphoma, HIV, thalassemia, polyarteritis nodosa, other blood disorders):
(including hay fever, asthma, emphysema, tuberculosis, lung cancer, pneumonia, cystic fibrosis, other lung diseases):
(including appendicitis, ulcer of stomach or duodenum, gall stones, hepatitis A (infectious), hepatitis B (serum), hepatitis C, cirrhosis of the liver, hemochromatosis, other liver diseases, colon cancer, ulcerative colitis, Crohn's disease, pyloric stenosis, rectal disorder, multiple polyps of the colon, inflammatory bowel disease, cystic fibrosis, intestinal cancer, any other problem of the digestive system):
(including diabetes mellitus, childhood diabetes, hypoglycemia, thyroid cancer, thyroid disease, goiter, adrenal dysfunction or disorder, metabolism disorder, hyperactivity, obesity, dwarfism):
(including kidney disease, diseases of urinary tract (urethra, bladder, ureter), rectal disorder, polycystic kidneys, kidney stones):
(including uterine fibroids, hermaphroditism/ambiguous genitals, undescended testicle, hypospodiasis, prostate cancer, ovarian cysts, cancer of ovaries, pelvic inflammatory disease, endometriosis, breast cancer, multiple miscarriages, stillbirths, childhood deaths):
(including 2 or more miscarriages, stillborn, premature menopause, death of a newborn infant, childhood death, birth defects, infertility, premature birth):
(including migraines, mental retardation, senility before age 50, multiple sclerosis, cerebral palsy, multiple sclerosis, epilepsy, ADD/hyperactivity, autism / asperger’s, hydrocephalus, tuberous sclerosis, disorder of spinal cord, Huntington's chorea, Gaucher's disease, myasthenia gravis, Wilson's disease, Creutzfeldt-Jacob disease, Alzheimer's disease, Parkinson’s disease, neurofibromatosis, scoliosis, Tay Sachs, Canavan disease, tourette’s syndrome, other diseases of nervous system):
(including anxiety/panic attacks, anorexia/bulimia/other eating disorders, schizophrenia, manic depressive, bipolar disorder, alcoholism, drug abuse/misuse/addiction, depression, suicide/attempted suicide, nervous breakdown, mental retardation, criminal convictions, or other disorders requiring hospitalization):
(including muscular dystrophy, lupus, deformity of spine, osteoporosis, dwarfism growth problem, brittle bones, loss of muscle coordination, marfan syndrome, rheumatoid or juvenile arthritis, spinal muscular atrophy, hereditary low back disease/scoliosis, arthritis, gout, Lupus, Reiter’s disease, myasthenia gravis, other chronic muscle disease):
(including deafness before age 60, deformity of the ear, cataracts before age 50, blindness, color blindness, severe myopia, glaucoma, retinoblastoma, retinitis pigmentosa, deviated septum, any other disorders):
(including acne, albinism eczema, skin cancer, excessive facial hair (Hirsutism), pigmentation disorders, psoriasis, neurofibromatosis, infectious skin disease, other skin disorders):
Congenital Abnormalities/Birth Defects
(including cleft lip/palate, congenital hip problems, club feet, heart defect, hearing problems, Spina Bifida (open spine), microcephaly, holoprosencehpaly, other):
(including down syndrome, Turner, Fragile X, other):
(including alcoholism, drug abuse/misuse/addiction, premature degeneration of any organ system, any other condition):
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