Initial Survey

There are many criteria that are used in determining qualified egg donors.  Our first step towards determining whether you qualify to be an egg donor is the Initial Survey.  To see if you qualify to become an egg donor, please fill out all the fields below. A member of our staff will get in touch with you.

Name:

 

Date of Birth:

 

Ethnicity:

 

Address:

 

Email:

     

Home Phone:

 

Work Phone:

Cell:

Height:

in  

Weight:

in  

Body Mass Index:

    

Tobacco use:

YesNo  Comments:  

Alcohol use:

YesNo  Comments:  

Drug use:

YesNo  Comments:  

Tatoos/Piercings within 1 year:

YesNo  Comments:  

Medical Illness:

YesNo  Comments:  

Previous Surgery:

YesNo  Comments:  

Marital Satus:

YesNo  Comments:  

Monogamous:

YesNo  Comments:  

Currently in Relationship:

YesNo   

Have both ovaries:

YesNo   

Have monthly periods:

YesNo   

Previous pregnancies:

YesNo   

Medications currently on:

 

Date of last period:

 

Current form of birth control:

 

Are you willing to self-administer daily injections for up to 5 weeks?

YesNo  

Are you aware you will have to stop using hormonal birth control?

YesNo     

Flexibility in work hours?

YesNo  

Would you be able to come to the office for frequent/daily monitoring?

YesNo  


Why do you want to be an egg donor?    

How did you hear of our program?