This information will be kept in your medical record and is strictly confidential. These forms are not released to anyone without your written permission. This information is used to evaluate your health and to match your characteristics with oocyte recipients' characteristics. We appreciate your honesty in answering these questions. Thank you.


Name
Address
City
State
Zip
Country
E-mail
Phone
Fax

CHARACTERISTICS:
Age
Date of Birth
Hair color
Eye color
Height
Weight
Blood type
Complexion
Race/Ethnic background
Religion, if any

EDUCATION:

Number of years completed
Degrees earned:
Occupation:
Hobbies and interests (please list at least 2)

MEDICAL HISTORY
Previous pregnancies
Previous infertility problems
How long did it take you to get pregnant (in months)?
Number of eggs in any previous cycle
Dates of previous egg donation cycles
Outcome of previous egg donation cycle (i.e. no oocytes obtained, fertilization, pregnancy)
Do you smoke?
  If so, how much?
  For how long?
Do you use drugs for recreational use?
  If so, what drugs?
Do you ever drink alcohol?
  If so, how much?
  How often?
Current medications
Medications within last 5 years:
Have you ever had any medical problems (asthma, diabetes, seizure disorders)?
Have you ever had a venereal disease (sexually transmitted disease)?
Have you ever had any experience as a research volunteer?
Have you ever had a blood transfusion?
How many male sexual partners have you had in the past?
Have you ever had sexual contact with homosexual men?
Have you ever had sexual contact with bisexual men?

Do you have or does anyone in your family have the following?
Blood testing:
Venereal Disease HIV  
Hepatitis Cytomegalovirus  
Cervical cultures:
Herpes Gonorrhea Chlamydia

FAMILY HISTORY:

Please describe family members' health:
Maternal grandmother
Maternal grandfather
Paternal grandmother
Paternal grandfather
Mother
Father
Siblings
Children
Any congenital malformations known in the family?
Any psychiatric illnesses or hospitalizations known in the family?

Please describe family members' health:

 
Mother
Father
Siblings
Age
Race
Religion
Cause of death
Serious illness

Please describe your children:

 
Child 1
Child 2
Child 3
Birthdate
Sex
Illnesses
Medications

Please describe your relationships:
Husband
Family
Children

If single, do you have a boyfriend?

How long have you been sexually active with your current sexual partner?

Please describe your personality:

Extroverted Worrier Leader
Aggressive Emotional Temperamental
Passive Friendly Angry
Other:

Do you have or has anyone in your family had: (explain below)

Disorder Yes No
Who (Relation)
Blood disorders (thalassemia, sickle cell, hemophilia)
Color blindness
Tay-Sachs (blindness, childhood death)
Mental retardation
Huntington's chorea (involuntary movement)
Diabetes (problems with sugar)
P.K.U. (special diet needed to prevent retardation)
Severe allergies (eczema, asthma)
Cystic fibrosis (lung disease, thick mucus)
Epilepsy (fits, convulsions, seizures)
Hydrocephalus (water on the brain)
Glaucoma (eye disorder)
Multiple sclerosis, Parkinson's Disease (nervous disorders)
Spina bifida (deformed backbone)
Congenital hearing problems or malformation
Chromosome abnormalities, including Down's Syndrome
Mental illness
Alcoholism
Heart disease at an early age
Please explain:

Additional Comments:



310 South Limestone Street, Lexington, KY 40503 USA
P.O. Box 23777 " Lexington, KY 40523 USA
Phone: (859) 254-8108, (859) 226-7263, (859) 226-7264
Fax: (859) 226-0026
E-mail: