Golden Egg Donation | Profile form_copy TRIXIE

Email Address:

First Name:

Last Name:

Date of birth:

Are you adopted?
YesNo

Height:

Weight:

Eye Color:

Hair Color:

Hair Color as child:

Hair Texture:
curlywavystraight

Baldness:

Baldness in Family:

Premature Graying:

Skin Complexion:
fairmediumolivedark

Skin Condition:
oilymediumdrycombination

Tan Ability:
noneeasymediumfreckle

Dominant Hand:
rightleftambidextrous

Vision:
glassescontactslaser surgerynone

Vision Quality (without corrective lenses):

Hearing (without corrective aids):

Blood Type:

Teeth:
poorfairgoodexcellent

Any periodontal or orthodontic work?

Ethnic Origin (list countries):

Mother:

Father:

Religion:

Religion Born Into:

Pregnancies?

Number of children?

Current Occupation:

How long have you been at your current occupation:

Academics

High School G.P.A:

SAT/ACT score:

College:

Major:

G.P.A:

Degrees:

Any learning disabilities or weaknesses in school?
yesno

If yes, please describe:

Academic Strengths (i.e. math, reading):

Career goals:

Personal goals:

What have you accomplished so far?

What are some awards/achievements you are proud of?

Personality

Hobbies:

Artistic Abilities (i.e. musical, painting):

Sports/Athletics:

Favorite subject in school:

Favorite Books:

Favorite Movies:

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?
yesno

Are you open to donating to a single Female?
yesno

Are you open to donating to a gay person or gay couple?
yesno

Family:

PGF=Paternal Grandfather PGM=Paternal Grandmother
MGF=Maternal Grandfather MGM=Maternal Grandmother

Father

Age (living):

Age (time of death):

Cause of Death:

Height:

Hair Color:

Eye Color:

Mother

Age (living):

Age (time of death):

Cause of Death:

Height:

Hair Color:

Eye Color:

PGF

Age (living):

Age (time of death):

Cause of Death:

Height:

Hair Color:

Eye Color:

PGM

Age (living):

Age (time of death):

Cause of Death:

Height:

Hair Color:

Eye Color:

MGF

Age (living):

Age (time of death):

Cause of Death:

Height:

Hair Color:

Eye Color:

MGM

Age (living):

Age (time of death):

Cause of Death:

Height:

Hair Color:

Eye Color:

Sibling 1 (M/F)

Age (living):

Age (time of death):

Cause of Death:

Height:

Hair Color:

Eye Color:

Sibling 2(M/F)

Age (living):

Age (time of death):

Cause of Death:

Height:

Hair Color:

Eye Color:

Sibling 3(M/F)

Age (living):

Age (time of death):

Cause of Death:

Height:

Hair Color:

Eye Color:

Sibling 4(M/F)

Age (living):

Age (time of death):

Cause of Death:

Height:

Hair Color:

Eye Color:

Child 1

Age (living):

Age (time of death):

Cause of Death:

Height:

Hair Color:

Eye Color:

Child 2

Age (living):

Age (time of death):

Cause of Death:

Height:

Hair Color:

Eye Color:

Mother's Occupation:

Mother's level of education:

Describe your mother's personality:

Father's Occupation:

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?

Personalities?

Sibling 2 Occupation:

Sibling 2 level of education:

Describe your sibling 2 personality:

Number of children?

Sex of children?

Personalities?

Sibling 3 Occupation:

Sibling 3 level of education:

Describe your sibling 3 personality:

Number of children?

Sex of children?

Personalities?

Sibling 4 Occupation:

Sibling 4 level of education:

Describe your sibling 4 personality:

Number of children?

Sex of children?

Personalities?

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?
yesno

If yes, what was the cause?

Do any members of your family have a history of learning disabilities or autism?
yesno

If yes, please explain:

Genetic History
Race: Check all that apply for your ancestors

African American
MotherFatherMGMMGFPGMPGF

Jewish
MotherFatherMGMMGFPGMPGF

Mediterranean
MotherFatherMGMMGFPGMPGF

Hispanic
MotherFatherMGMMGFPGMPGF

Indian (India)
MotherFatherMGMMGFPGMPGF

Southeast Asian
MotherFatherMGMMGFPGMPGF

French Canadian
MotherFatherMGMMGFPGMPGF

Cajun
MotherFatherMGMMGFPGMPGF

Have you or anyone in your family ever been tested positive as a carrier or had any of the following diseases?

Blooms Syndrome
yesno