1. First Name
 
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2. Last Name
 
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3. What is your home address?
 
Address Street Address City State Zip Code
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4. Distance from Austin, Texas
 
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5. Primary Phone (include area code)
 
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6. Secondary Phone (include area code)
 
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7. Date of birth
 
   
8. Height
 
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9. Weight
 
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10. Race
 
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11. What is the highest level of education you have completed?
 
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12. Are you adopted?
 
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13. Are you pregnant or breastfeeding?
 
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14. Have you ever been told you are infertile by a doctor?
 
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15. Have you been vaccinated in the past 6 months?
 
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If yes, when and for what?
16. Do you have any history of any significant emotional or psychological problems?
 
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If yes, please explain.
17. Are you currently under a physician's care for any reason?
 
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If yes, please explain.
18. List all medications that you have taken in the proceeding 12 months (prescription). Enter "N/A" in the first box if you have not taken medications.
 
Rx Medications Medication How Often Reason
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19. List all current over-the-counter medications (including hormones, vitamins, aspirin, antacids, laxatives, herbal & sports supplements, performance-enhancing supplements including steroids, etc.). Enter "N/A" in the first box if you have not taken any OTC medications.
 
OTC Medications Medication How Often Reason
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20. Are there any known genetic diseases or conditions that run in your family?
 
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If yes, please explain
21. Please explain any personal or family related medical conditions that you are aware of?
 
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22. Do you have medical insurance?
 
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23. Within the preceding 12 months, have you undergone tattooing, ear piercing, or body piercing in which sterile procedures were not used e.g., contaminated instruments and/or ink were used, or shared instruments that had not been sterilized between procedures were used?
 
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Please Explain
24. When is the last time you used other recreational or illicit drugs (cocaine, LSD, heroin, barbiturates, narcotics, opiates, amphetamines, hallucinogens, tranquilizers, PCP, steroids, or etc.)?
 
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If yes, which one(s) and when.
25. When is the last time you had marijuana?
 
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26. Have you ever been convicted of a felony?
 
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If yes, please explain your conviction.
27. Are you eligible to work in the United States?
 
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28. Are you a US Citizen or permanant resident?
 
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29. Have you applied or been screened to be an egg donor before?
 
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If yes, provide the name and location of the donor program(s).
30. Previous Donor
 
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31. How many times have you donated your eggs?
 
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32. Are you currently enrolled as an egg donor in another program?
 
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33. How did you hear about TFC's egg donor program?
 
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Other
34. What is your email address for communication with you regarding your pre-screen application?
   
35. What is your preferred password for future login reference?
   (6-20 characters with 4 or more letters and 1 or more numbers)  
36. Verify your password.
   

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