EDPM - Egg Donor Program of Michigan

PERSONAL INFORMATION

Date filled:

(mm/dd/yyyy)

Name:

DOB:

(mm/dd/yyyy)

Age:

Marital Status:

Single Engaged Married Divorced Widowed

Mailing Address

City:

State Zip Code

Home Telephone:

OK to leave a message? Yes or no

Work Telephone:

OK to leave a message? Yes or no

Mobil number:

OK to leave a message? Yes or no

Email Address:

Would you be willing to travel out of the state to donate? Yes or no

(If you are traveling a long distance, the majority of your travel costs will not be your responsibility)

Do you own a car?

Yes or no

Your current occupation is

How long have you been employed in this occupation?

PRIOR DONOR HISTORY

(We will need copies of these records sent to us – blood tests, psych screen, cycle sheet)

Have you ever been an oocyte donor before? Yes or no

If yes, when?

and Where?

Do you know how many eggs were produced each time? Yes or no If YES - how many

Do you know how many births have resulted from these donations? Yes or no If YES - how many

PERSONAL CHARACTERISTICS

Race

Height

Weight

lbs

Natural Hair Color

Natural Eye Color

Hair

Thick Thin Average

Hair

Curly Wavy Straight

Complexion

Fair Medium Dark

Blood Type (if known)

Are you

Right handed Left handed Ambidextrous

Do you have any dimples, freckles, birthmarks? Yes or No

If yes, explain where

Body Type

Small Medium Large Other

Were you adopted?

Yes or No

Ethnic Origin/Ancestry: (Example: French, Irish,Brazilian, etc.)

Mother’s side:

Father’s side:

Religion by birth:

Religion now:

PREGNANCY HISTORY

Have you ever had a miscarriage and/or abortion? Yes or No If YES, when?

Are you currently breastfeeding?

Yes or No

If you have been pregnant before, please fill out the table below:

	Year/Your Age	Sex and Age of Child	Duration	Complications/Healthy
1
2
3
4

REPRODUCTIVE HISTORY

1. Age of first period

Regular, or Irregular

2. Interval between period (count start of flow to start of next flow) Days?

3. Do you have menstrual cramps?

Yes or No: If yes, describe

4. Do you have any bleeding in between your periods? Yes or No

5. When was your last pap smear?

Month Year

If over a year, would you be willing to have it repeated? Yes or No

6. Have you ever had an abnormal pap smear? Yes or No: If yes, when

Have you had a normal pap smear since? Yes or No: If yes, when

7. Do you have discharge from one or both breasts? Yes or No

8. Have you ever had endometriosis?

Yes or No

9. Have you ever had pelvic inflammatory disease? Yes or No

10. Have you ever had any of the following? (leave blank for the ones you don't have)

	Date	Age	Treatment
Gonorrhea
Chlamydia
Condyloma (venereal warts)
Syphilis
Herpes
Other

11. Did your mother take DES when she was pregnant with you? Yes or No Not Sure

12. Is there a history of infertility in your family? Yes or No Not Sure

If Yes, please explain

CONTRACEPTIVE / SEXUAL HISTORY

What contraceptives have you used?

Type	When	How Long	Reaction
The Pill
IUD
Diaphragm
Condom
The Patch
Depo Provera

1. What method do you currently use?

2. Which method does your partner currently use?

3. Are you:

Heterosexual Homosexual Bisexual

3. Are you sexually active now

Yes or No

5. Are you currently sexually active with a partner? Yes or No

6. How long have you been with your partner?

7. Is your relationship monogamous?

Yes or No Not Sure

8. How many partners have you had in the past 1 year?

PERSONAL HEALTH HISTORY

1. Do you currently have any allergies?

Yes or No

If yes, are they to

food drugs environmental other

Please list specific substances and reaction(s) produced:

Substance	Reaction

2. Do you have any allergies that you have outgrown? Yes or No:

If yes, please explain:

3. Has anyone in your family, including yourself, experienced recurring and/or chronic physical symptoms that have not yet been evaluated by a physician? Please include those symptoms that you might not consider serious.
Yes or No: If yes, please explain

4. How is your vision (without glasses)?

Poor Fair Good Excellent

Do you wear glasses or contact lenses?

Yes or No: If yes, which do you wear?

5. Do you have normal hearing?

Yes or No: If No, please explain

6. What is the condition of your teeth?

Poor Fair Good Excellent

7. Did you ever wear a retainer or braces? Yes or No: If Yes, please explain

8. Your diet:

Vegetarian Non Vegetarian

Your appetite

Poor Fair Good Excellent

9. How much do you currently exercise?

None Some Regularly

What type of exercise do you enjoy?

10. Have you ever had surgery?

Yes or No: If Yes, please explain

11. Have you had any hospitalization not previously mentioned? Yes or No

If Yes, please explain

12. Have you had major radiation or x-ray exposure? Yes or No

If Yes, please explain

13. Have you ever had a blood transfusion? Yes or No: If Yes, when?

14. Have you ever smoked cigarettes?

Yes or No

If yes, complete below:

Current Smoker Former Smoker

age started number per day age quit

15. Have you ever had any complication resulting from surgery (bleeding embolism, coma) or anesthesia?
Yes or No: If Yes, please explain

16. Have you or any member of your family had malignant hyperthermia or high fevers after surgery, injury, or exercise?
Yes or No: If Yes, please explain

17. Do you take any medications at the present time?
Yes or No: If Yes, which ones?

18. Have you ever been advised to have any diagnostic testing, hospitalization, or surgery which was not completed?
Yes or No: If Yes, please explain

19. Have you ever had any serious trauma? Yes or No: If Yes, please explain

20. Have you gained or lost more than 10 pounds in the past year?
Yes or No: If Yes, please explain

21. Have you ever participated in mental health counseling?
Yes or No: If Yes, please explain

22. What kind of alcoholic beverages do you drink?

23. How many drinks (beer, wine, alcohol) do you consume?
per day per week per month?

24. Have you ever used intravenous drugs? Yes or No

25. Have you ever been with a partner who may have used intravenous drugs? Yes or No

26. Have you had and/or been treated for a substance/alcohol abuse/addiction problem? Yes or No

27. Do you have any legal cases pending against you?
Yes or No: If Yes, please explain

28. Have you ever filed bankruptcy?

Yes or No

29. Have you ever been convicted of a crime? Yes or No: If Yes, please explain

Would you prefer to do an anonymous donation? Yes or No Either

Do you prefer, or are you willing, to talk to or meet the prospective parents? Yes or No
If so, please elaborate:

Would you be willing to meet a child conceived as a result of your donation? Yes or No

Have you told any family or friends about your decision to donate? Yes or No
If so, who have you told, and are they supportive? Yes or No

Are you willing to donate to gay prospective parents? Yes or No

Are you willing to donate to international prospective parents? Yes or No

Are you willing to donate to all ethnicities? Yes or No

Are you willing to donate to a single prospective parent? Yes or No

Are there any types of prospective parents who you will not donate to? Yes or No
If so, please elaborate:

EDUCATION

Please include GPA if known:

Completed grade school

Yes No

Completed High School

Yes No -

>List any clubs, sports, school activities, honors, etc

Completed some college/area of study Yes No -

Currently in college/area of study Yes No -

>List any clubs, sports, school activities, honors, etc

Completed college/degree

Yes No -

>List any clubs, sports, school activities, honors, etc

Currently pursuing postgraduate degree Yes No -

>List any clubs, sports, school activities, honors, etc

Completed advanced degree

Yes No -

INDIVIDUAL QUESTIONS

Your personality and character. Check those that apply:

Extrovert	Aggressive	Passive	Warm
Slight Extrovert	Assertive	Sensitive	Happy
Introvert	Shy	Moody	Lonely
Slight Introvert	Quiet	Dependent	Energetic
	Average	Independent

Other qualities that stand out unique to your personality:

Why do you want to be an egg donor?

What do you like most about yourself?

What are your personal interests, talents, special skills, or activities you enjoy:

What are you doing at this point in your life?

What are your future goals?

What else would you like the recipient of your donation to know about you?

	As an adult my favorites are	As a child my favorites were:
Food:
Color:
Season:
Book:
TV Program:
Music:
Movies:

What is your favorite memory as a child?

When you were a child, what did you want to be when you grew up?

Have you ever been tested to determine if you carry the Cystic Fibrosis gene? Yes or No

Are you or any of your family members known carriers of the Cystic Fibrosis gene? Yes or No

Have you ever been tested to determine if you carry the Tay Sachs gene? Yes or No

Are you or any of your family members known carriers of the Tay Sachs gene? Yes or No

Have you ever been tested to determine if you carry the Fragile X gene? Yes or No

Are you or any of your family members known carriers of the Fragile X gene? Yes or No

FAMILY CHARACTERISTICS

Biological Mother:

Age if alive

Age at death

Medical problems or cause of death

Occupation and/or Schooling: (If
retired, occupation before retiring?)

Eye color:

Hair color (If gray now,
what was it before)

Complexion:

Fair Medium Dark

Body type:

Small Medium Large

Height:

Weight:

Biological Father:

Age if alive

Age at death

Medical problems or cause of death

Occupation and/or Schooling: (If
retired, occupation before retiring?)

Eye color:

Hair color (If gray now,
what was it before)

Complexion:

Fair Medium Dark

Body type:

Small Medium Large

Height:

Weight:

Biological Maternal Grandmother:

Age if alive

Age at death

Medical problems or cause of death

Occupation and/or Schooling: (If
retired, occupation before retiring?)

Eye color:

Hair color (If gray now,
what was it before)

Complexion:

Fair Medium Dark

Body type:

Small Medium Large

Height:

Weight:

Biological Maternal Grandfather:

Age if alive

Age at death

Medical problems or cause of death

Occupation and/or Schooling: (If
retired, occupation before retiring?)

Eye color:

Hair color (If gray now,
what was it before)

Complexion:

Fair Medium Dark

Body type:

Small Medium Large

Height:

Weight:

Biological Paternal Grandmother:

Age if alive

Age at death

Medical problems or cause of death

Occupation and/or Schooling: (If
retired, occupation before retiring?)

Eye color:

Hair color (If gray now,
what was it before)

Complexion:

Fair Medium Dark

Body type:

Small Medium Large

Height:

Weight:

Biological Paternal Grandfather:

Age if alive

Age at death

Medical problems or cause of death

Occupation and/or Schooling: (If
retired, occupation before retiring?)

Eye color:

Hair color (If gray now,
what was it before)

Complexion:

Fair Medium Dark

Body type:

Small Medium Large

Height:

Weight:

Sibling 1:

Age if alive

Age at death

Medical problems or cause of death

Occupation and/or Schooling: (If
retired, occupation before retiring?)

Eye color:

Hair color (If gray now,
what was it before)

Complexion:

Fair Medium Dark

Body type:

Small Medium Large

Height:

Weight:

Sibling 2:

Age if alive

Age at death

Medical problems or cause of death

Occupation and/or Schooling: (If
retired, occupation before retiring?)

Eye color:

Hair color (If gray now,
what was it before)

Complexion:

Fair Medium Dark

Body type:

Small Medium Large

Height:

Weight:

Sibling 3:

Age if alive

Age at death

Medical problems or cause of death

Occupation and/or Schooling: (If
retired, occupation before retiring?)

Eye color:

Hair color (If gray now,
what was it before)

Complexion:

Fair Medium Dark

Body type:

Small Medium Large

Height:

Weight:

Sibling 4:

Age if alive

Age at death

Medical problems or cause of death

Occupation and/or Schooling: (If
retired, occupation before retiring?)

Eye color:

Hair color (If gray now,
what was it before)

Complexion:

Fair Medium Dark

Body type:

Small Medium Large

Height:

Weight:

Sibling 5:

Age if alive

Age at death

Medical problems or cause of death

Occupation and/or Schooling: (If
retired, occupation before retiring?)

Eye color:

Hair color (If gray now,
what was it before)

Complexion:

Fair Medium Dark

Body type:

Small Medium Large

Height:

Weight:

(Please use the box below outlining the above information if there are any additional siblings and ½ siblings in your family.)

Have twins or other multiple births occurred in your family?
Yes or No: If Yes, please explain

MEDICAL BACKGROUND

In the next several pages indicate if your grandparents, parents, siblings, children, aunts, uncles, cousins or other extended family members (blood relatives) have had or now have any of the following medical conditions listed below. Please note with aunts, uncles, or cousins if on the maternal or paternal side of the family. Where appropriate, give age at onset, treatment, medication, etc. Use additional space on the back page if needed.

	Heart	Self Yes or No	Family Yes or No	If YES Please Describe
1	Stroke	Yes No	Yes No
2	Heart attack	Yes No	Yes No
3	Heart disease a. From Birth	Yes No	Yes No
	b. Other	Yes No	Yes No
4	Heart murmur	Yes No	Yes No
5	Hardening of the arteries	Yes No	Yes No
6	High blood pressure	Yes No	Yes No
7	High cholesterol	Yes No	Yes No

	Blood	Self Yes or No	Family Yes or No	If YES Please Describe
1	Anemia	Yes No	Yes No
2	Sickle-cell anemia	Yes No	Yes No
3	Hemophilia or other bleeding problem	Yes No	Yes No
4	Leukemia	Yes No	Yes No
5	Immune deficiency	Yes No	Yes No
6	Thalassemia	Yes No	Yes No
7	Other blood disorder	Yes No	Yes No

	Respiratory (Lungs)	Self Yes or No	Family Yes or No	If YES Please Describe
1	Hay fever	Yes No	Yes No
2	Asthma	Yes No	Yes No
3	Emphysema	Yes No	Yes No
4	Tuberculosis	Yes No	Yes No
5	Lung cancer	Yes No	Yes No
6	Pneumonia	Yes No	Yes No
7	Cystic Fibrosis	Yes No	Yes No
8	Other Lung disease	Yes No	Yes No


	Gastro-Intestinal	Self Yes or No	Family Yes or No	If YES Please Describe
1	Ulcer of stomach or Duodenum	Yes No	Yes No
2	Gallstones	Yes No	Yes No
3	Hepatitis A (infectious)	Yes No	Yes No
4	Hepatitis B_(serum)	Yes No	Yes No
5	Hepatitis C	Yes No	Yes No
6	Other liver disease	Yes No	Yes No
7	Colon cancer	Yes No	Yes No
8	Ulcerative colitis	Yes No	Yes No
9	Crohn’s disease	Yes No	Yes No
10	Intestinal cancer	Yes No	Yes No
11	Cirrhosis	Yes No	Yes No
12	Pyloric Stenosis	Yes No	Yes No
13	Rectal disorder	Yes No	Yes No
14	Any other problem of the digestive system	Yes No	Yes No

	Metabolic/Endocrine	Self Yes or No	Family Yes or No	If YES Please Describe
1	Diabetes mellitus	Yes No	Yes No
2	Hypoglycemia	Yes No	Yes No
3	Thyroid disease	Yes No	Yes No
4	Thyroid cancer	Yes No	Yes No
5	Goiter	Yes No	Yes No
6	Adrenal dysfunction	Yes No	Yes No
7	Phenyl Ketonuris (PKU)	Yes No	Yes No

	Urinary	Self Yes or No	Family Yes or No	If YES Please Describe
1	Kidney disease	Yes No	Yes No
2	Kidney stones	Yes No	Yes No
3	Other diseases of the urethra, bladder, ureter	Yes No	Yes No

	Genital/Reproductive	Self Yes or No	Family Yes or No	If YES Please Describe
1	Undescended testicle	Yes No	Yes No
2	Hypospadias	Yes No	Yes No
3	Prostate cancer	Yes No	Yes No
4	Uterine fibroids	Yes No	Yes No
5	Endometriosis	Yes No	Yes No
6	Cervical cancer	Yes No	Yes No
7	Ovarian cancer	Yes No	Yes No
8	Ovarian cysts	Yes No	Yes No
9	Uterine cancer	Yes No	Yes No
10	Spontaneous abortion,miscarriage, stillbirth	Yes No	Yes No
11	Early infant death	Yes No	Yes No
12	Premature menopause	Yes No	Yes No
13	Hermaphroditism	Yes No	Yes No
14	Ambiguous Genitals	Yes No	Yes No

	Neurological	Self Yes or No	Family Yes or No	If YES Please Describe
1	Migraines	Yes No	Yes No
2	Mental Retardation	Yes No	Yes No
3	Down’s syndrome	Yes No	Yes No
4	Turner’s syndrome	Yes No	Yes No
5	Fragile X	Yes No	Yes No
6	Multiple sclerosis	Yes No	Yes No
7	Cerebral palsy	Yes No	Yes No
8	Epilepsy, seizures	Yes No	Yes No
9	Hydrocephalus	Yes No	Yes No
10	Spinal Cord disorder	Yes No	Yes No
11	Huntington’s chorea	Yes No	Yes No
12	Gaucher’s disease	Yes No	Yes No
13	Canavan’s disease	Yes No	Yes No
14	Tay sach’s	Yes No	Yes No
15	Wilson’s disease	Yes No	Yes No
16	Parkinson’s disease	Yes No	Yes No
17	Alzheimer’s disease	Yes No	Yes No
18	Senility before age 50	Yes No	Yes No
19	Other diseases of the Nervous system	Yes No	Yes No

	Mental Health	Self Yes or No	Family Yes or No	If YES Please Describe
1	Schizophrenia	Yes No	Yes No
2	Manic depression	Yes No	Yes No
3	Depression	Yes No	Yes No
4	Suicide	Yes No	Yes No
5	Other mental health disorders requiring hospitalization	Yes No	Yes No

	Muscular/Bones/Joints	Self Yes or No	Family Yes or No	If YES Please Describe
1	Muscular dystrophy	Yes No	Yes No
2	Other chronic Muscle disease	Yes No	Yes No
3	Lupus	Yes No	Yes No
4	Deformity of spine/Spina Bifida	Yes No	Yes No
5	Osteoporosis	Yes No	Yes No
6	Dwarfism	Yes No	Yes No
7	Rheumatoid arthritis	Yes No	Yes No
8	Osteoarthritis	Yes No	Yes No
9	Gout	Yes No	Yes No
10	Cleft Palate/Cleft lip	Yes No	Yes No
11	Marfan syndrome	Yes No	Yes No

	Sight/Sound/Smell	Self Yes or No	Family Yes or No	If YES Please Describe
1	Deafness before age 60	Yes No	Yes No
2	Deformity of the ear	Yes No	Yes No
3	Cataracts before age 50	Yes No	Yes No
4	Blindness	Yes No	Yes No
5	Color blindness	Yes No	Yes No
6	Deviated septum	Yes No	Yes No
7	Glaucoma	Yes No	Yes No
8	Retinitis Pigmentosa	Yes No	Yes No
9	Any other sight/sound/smell disorder	Yes No	Yes No

	Skin	Self Yes or No	Family Yes or No	If YES Please Describe
1	Acne	Yes No	Yes No
2	Eczema	Yes No	Yes No
3	Skin cancer	Yes No	Yes No
4	Pigmentation disorder	Yes No	Yes No
5	Neurofibromatosis	Yes No	Yes No
6	Other disorders of the skin	Yes No	Yes No

	Other	Self Yes or No	Family Yes or No	If YES Please Describe
	Alcoholism	Yes No	Yes No
	Drug abuse, misuse or addiction	Yes No	Yes No
	Breast cancer	Yes No	Yes No
	Early death, Before age 50	Yes No	Yes No
	Any other cancer not mentioned	Yes No	Yes No
	Congenital hip problems	Yes No	Yes No
	Club feet	Yes No	Yes No
	Any other condition not mentioned	Yes No	Yes No

Donor Consent

I have answered all the questions to the best of my ability and the answers to my knowledge are
correct.

I am aware that all the information on the preceding pages (except for identifying information on
page one) can be released to the potential recipient of my donated oocytes.

Signed: Date

Egg Donor Program of Michigan is located at:
5090 State Street - Suite 103 B
Saginaw, MI 48603
Phone: 989.791.9712 Fax: 989.791.8144
Email: info@eggdonorofmichigan.com