Full Name: *
Date of Birth (M/D/Y): *
Phone Number: *
Hobbies (What activities do you enjoy?):
Are you musically inclined? If so, please specify:
List any sports you participate in:
List any skills/hobbies you have:
What is your highest level of education: *
High School GPA: *
SAT/ACT score (please specify): *
College GPA: *
Currently attending school? List degrees held:
Learning disabilities? If yes, describe:
Whats your occupation: *
What type of work do you do? *
Any exposure to chemicals? If yes, please describe: What things make you worry? (Please check all that apply) Most people consider me: (please check at least one) * I consider myself to be: (please check at least one) * Are you satisfied with your lifestyle? Do you have specific goals? Have you ever had any suicidal thoughts? * Have you ever had an eating disorder? *
How did you hear about our donor program and what prompted you to become involved as an oocyte (egg) donor?
Are you in complete understanding and willing to donate your eggs to anonymous couples, which could give birth to children that are genetically similar to yourself? You will never know the outcome of the situation, and these hypothetical children could be raised in the Tampa Bay area, frequenting places you will go as well. This situation is not to scare you it is to make you thoroughly evaluate your decision to become an egg donor.
You could be contacted (although the chance is slim) later on in life if a child that was conceived using your oocyte has a serious medical condition that may require a blood or bone marrow match. The contact may be simply to get a medical history from you in order to better manage a medical treatment for that child. It may be hard to imagine how you may feel in the future, but entertain the idea how you and your future family will feel knowing this person exists and the affect on others if you decide to keep your egg donation private.
Will you keep your donation private from others, and if not how does your family and spouse feel about your decision to donate your eggs? In the State of Florida, your spouse is required to know about your donation and must sign a consent before retrieval.
We have many different couples that come to us in need of donor eggs; your services are greatly needed. However, not all of our couples are in traditional family relationships. We have same sex partners and people who are unable not only to use their own eggs but may need a surrogate to carry the baby or donor sperm to fertilize the eggs. You need to be aware of these particular possibilities and make sure you are comfortable with your part in these cycles. If you have a morale concern with donating in these situations you need to evaluate your feelings and perhaps reconsider being a donor. We have very few of these types of family dynamics, but they do exist and we will accommodate them if our IVF Medical Director agrees to their treatment. Most of our patients are traditional couples. Would you refuse to donate to this type of family dynamic?
Please express any concerns you may have with your involvement with our program and feedback on what you expect to learn from our orientation. Thank you for your openness and take the time to consider the questions we have brought to your attention.
Do you have any medication allergies? (Y/N) If yes, name medication and describe reaction: *
Have you ever received blood products or had a blood transfusion? If so, specify: *
Have you ever been rejected as a blood donor? If so, specify: *
Have you ever taken a medication for depression or anxiety? Please list: * Which of the following treatments have you ever received? (Check all that apply) *
Please specify if any of the treatments above apply:
Have you taken any non-prescription medication on a regular basis? If yes, please specify: *
Have you taken any prescription medication in the past six months? If yes, please specify: * Immunizations, check all that you have been immunized for: * Have you ever had any of the following? (check all that apply) *
Please elaborate if you answered yes to any of the above questions: General Surgery: Which of these types of surgery have you had? *
Specify each surgery and what year:
Do you smoke cigarettes, cigars, or a pipe? (Y/N) If yes, how much? * What best describes your consumption of alcohol? * What type of alcohol do you typically consume?
Have you ever been in a program for limiting or discontinuing use of alcohol? If yes what year: * How many cups of coffee/tea do you drink in an average day? * Do you now or have you ever used any of the following drugs? (check all that apply) *