Personal Profile Step 1 of 3 33% Donor Number*Assigned to you by Florida Fertility Institute (If you do not have this number please contact the IVF Department at 727-796-7705)Please enter a value between 1 and 500.Current Age*Please enter a value between 18 and 43.Height*feet and inchesWeight*Please enter a value between 50 and 250.Eye Color*Natural Hair Color*Hair Texture*eg. Straight, Wavy, Curly, etc.Complexion*Fair, Medium, Dark, etc.Marital Status*SingleMarriedDivorcedWidowedPredominant Hand* Left Right Ambidextrous Vision* Normal Glasses or Contacts Hearing*Normal or DescribeNative Language*(English, Spanish, etc)ReligionHave you ever been pregnant?*YesNo# of Pregnancies# of live births*# of miscarriages# of abortionsHave you ever been a donor?*YesNoAre you in generally good health?*YesNoIf no, describeRace*Ethnic Heritage*Have you ever received treatment for depressions?*YesNoIf yes, describeHave you ever been under the care of a psychiatrist?*YesNoIf yes, describeAre there any known genetic conditions or birth defects in your family?*YesNoIf yes, describeHobbies and recreationWhat activities do you enjoy?*List any sports you participate in?List any skills/hobbies you haveAre you musically inclined?*YesNoif so, please specifyEducationLevel of education*High School GPASAT ScoreACT ScoreCollege GPACollege MajorSrongest subjectsCurrently attending school?*YesNoList degrees heldLearning disabilities? If yes, describeEmploymentOccupation*What type of work do you do?*Any exposure to chemicals?*YesNoIf yes, please describe Self-AssessmentWhat things make you worry?* Job Family Money Health Sex Relationship with others Personal things Other (see next field) Other (specify)Most people consider me ...*Choose oneOutgoing/friendlyAverageQuiet/reservedUnpredictableI consider myself to be...*Choose oneOutgoing/friendlyAverageQuiet/reservedUnpredictableAre you satisfied with your lifestyle?*YesNoDo you have specific goals?YesNoHave you ever had any suicidal thoughts?*YesNoHave you ever had an eating disorder?*YesNoGeneral donor questionnaireWhat 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.*YesNoYou 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 out 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 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.Medications and treatmentsDo you have any medication allergies?*YesNoIf yes, name medication and describe reactionHave you ever taken a medication for depression or anxiety?*Which of the following treatments have you ever recieved?* Routine x-ray (dental/chest) Special x-ray study Radiation treatment (specify in next field) Chemotherapy (specify in next field) Hormone therapy (specify in next field) None of the above Specify treatmentsHave 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*ImmunizationsCheck what you have been immunized for:* Diptheria Polio Influenza Smallpox Measles Tetanus Mumps Whooping cough Hepatitis B Rubella Chicken pox Pertusis Pneumonia Hepatitis A Meningitis None Do not know Other :see next field Other ImmunizationsHave you ever had any of the following? (check all those that apply) Mumps Genital warts Chlamydia Hepatitis Gonorrhea Syphilis Herpes Mycoplasma Urea Plasma HIV/AIDS Sexually Transmitted diseases? (state type)Abnormal pap smear (please elaborate)If answered yes to any of the above questions, please elaborate:General SurgeryWhich of these types of surgery have you had?* Neurosurgery Ear Throat Vascular or Cardiac Nose Ophthalmology-eye Thyroid, thymus, adrenal Abdominal Plastic Urological Dental Orthopedic Protological Oral/facial Other (see next field) None of these Specify each surgery and what yearStimulant and substance abuseDo you smoke cigarettes, cigars, or a pipe? Yes or no.. If yes, how much?*What best describes your consumption of alcohol?*I don't drink alcoholic beveragesI drink rarely and in small amountI tend to consume evenly in amount throughout the weekI tend to consume in concentrated periodsWhat type? Beer Wine Cocktails Have you ever been in a program for limiting or discontinuing use of alcohol?*yesnoHow many cups of coffee/tea do you drink in an average day?*None1-34-67 or moreDo you now use any of the following drugs? Marijuana Hallucinogens (LSD, Mescaline, etc.) Cocaine Barbituates Anphetamines Narcotics PCP Intravenous drugs None of the above Have you ever used any of the following drugs? Marijuana Hallucinogens (LSD, Mescaline, etc.) Cocaine Barbituates Anphetamines Narcotics PCP Intravenous drugs None of the above Reproductive HistoryWhat age were you when you first started your period?*Do you have regular menstrual cycles?*YesNoDo you experience premenstrual syndrome?*YesNoHave you ever been an egg donor?*YesNoIf yes, when and where?Where you adopted?*YesNoHave you ever had any problems getting pregnant?YesNo Family HistoryAre there any known genetic disease or conditions that "run in the family"?*Do you have any handicaps either physical or mental occur in your family?*If yes please specifyIs there a history of early deaths in your family? (heart attack, etc)*Please elaborate if yesTo the best of your knowledge, please list if you or any of your blood relatives have ad any of the diseases or conditions listed below* None of these Alkapotonuria Alcoholism Alzheimer's disease Anemia Arthrosclerosis Arthritis Asthma Bleeding disorder Blood clots Cancer Cataracts (before age 40) Cleft lip or palate Club foot Congenital heart disease Congenital malformation Cystic fibrosis Deafness Depression Diabetes Downs syndrome Drug dependency Endometriosis Epididymitis Heart disease Hemophilia High blood pressure Huntington's disease Leukemia Low blood pressure Kidney or bladder disease Manic depression/psychosis Mental illness Mental retardation Muscular dystrophy Nervous disorders Neural tube defects Spina bifida, meningocoele Panic attacks PKU Pyloric stenosis Respiratory disease Retardation, physical Schizophrenia Seizures Congenital hip dislocation Coronary artery disease HIV Senility befoe age 50 Tetanus Thyroid problems Tumor Tuberculosis MotherNationalityAgeLiving/DeceasedLivingDeceasedCause of deathMother's Mother(maternal grandmother)NationalityAgeLiving/DeceasedLivingDeceasedCause of deathMother's Father(maternal grandfather)NationalityAgeLiving/DeceasedLivingDeceasedCause of deathGreat Grandmother(mother's mother's mother)NationalityAgeLiving/DeceasedLivingDeceasedCause of deathGreat Grandfather(mother's mother's father)NationalityAgeLiving/DeceasedLivingDeceasedCause of deathGreat Grandmother(mother's father's mother)NationalityAgeLiving/DeceasedLivingDeceasedCause of deathGreat Grandfather(mother's father's father)NationalityAgeLiving/DeceasedLivingDeceasedCause of deathFatherNationalityAgeLiving/DeceasedLivingDeceasedCause of deathFather's Mother(paternal grandmother)NationalityAgeLiving/DeceasedLivingDeceasedCause of deathFather's Father(paternal grandfather)NationalityAgeLiving/DeceasedLivingDeceasedCause of deathGreat Grandmother(father's mother's mother)NationalityAgeLiving/DeceasedLivingDeceasedCause of deathGreat Grandfather(father's mother's father)NationalityAgeLiving/DeceasedLivingDeceasedCause of deathGreat Grandmother(father's father's mother)NationalityAgeLiving/DeceasedLivingDeceasedCause of deathGreat Grandfather(father's father's father)NationalityAgeLiving/DeceasedLivingDeceasedCause of deathSection Break
