Egg Donor Program

of Michigan
5090 State Street - Suite 103 B
Saginaw, MI 48603
Phone: 989.791.9712 Fax: 989.791.8144
Email:

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Can I be a Donor?

FAQ

Questionnaire

Donor
Recipients

Overview of Process

Contact Me
 

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 or
   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 or
   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 or
   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 or
   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 or
   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 or
   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 or
   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 or
   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 or
   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 or
   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 or
   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
 

 

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