The Fertility Center
1. Please select the most accurate response to the decision tree related to your eligibility to work in the USA, your residency, and your citizenship.
 
2. FIRST name
 
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3. LAST name
 
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4. Street address? (include apartment if approprate)
 
--> Street Address Apartment City State Zip
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5. Based on the following address: (3230 Eagle Park Dr NE, Grand Rapids, MI 49525) ... how much time will it take to get to this location? (typical treatment cycle is 11 visits)
 
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6. How did you hear about our egg donation program?
 





Please Explain
7. What is the primary phone number (include area code) to use for contact and leaving messages?
 
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8. What is your marital / relationship status?
 
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9. Please select the most accurate response to the decision tree about your experience in donating your eggs.
 
10. Closest description of your race
 
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If multi-racial, please provide your closest description.
11. What is your date of birth?
 
   
12. Height
 
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13. Weight
 
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14. What is your highest level of completed education?
 
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15. Is your work schedule flexible?
 
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16. Have any of your jobs (or other activities) required prolonged exposure to chemicals?
 
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Please explain:
17. Have you been in juvenile detention, lock up, jail or prison for more than 72 consecutive hours in the preceding 12 months?
 
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18. 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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19. Have you been treated for or had Chlamydia trachomatis or Neisseria gonorrhea infection in the preceding 12 months?
 
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20. Have you spent 3 months or more, cumulatively, in the UK (England, Northern Ireland, Scotland, Wales, the Isle of Man, the Channel Islands, Gibraltar, or the Falkland Islands) from the beginning of 1980 through the end of 1996?
 
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21. Are you a current or former US military member, civilian military employee, or dependent of a military member or civilian employee, who has resided at US military bases in northern Europe (Germany, Belgium, and Netherlands) for 6 months or more cumulatively from 1980 through 1990, or elsewhere in Europe (Greece, Turkey, Spain, Portugal, or Italy) for 6 months or more cumulatively from 1980 through 1996?
 
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22. Have you lived cumulatively for 5 years or more in Europe (Albania, Austria, Belgium, Bosnia-Herzegovina, Bulgaria, Croatia, Czech Republic, Denmark, Finland, France, Germany, Greece, Hungary, Ireland, Italy, Liechtenstein, Luxembourg, Macedonia, Netherlands, Norway, Poland, Portugal, Romania, Slovak Republic, Slovenia, Spain, Sweden, Switzerland, England, Northern Ireland, Scotland, Wales, Isle of Man, Channel Islands, Gibraltar, Falkland Islands, and Yugoslavia) from 1980 until present?
 
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23. Please answer the following decision tree related to smoking habits (including any form of nicotine products, including e-cigarettes).
 
24. Please select the most accurate answer for the following question about smoking, drinking, marijuana and other drugs (Cocaine, Heroin, etc).
 
Recreational Drugs Smoking Alcohol Marijuana Other Drugs
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25. Please select the most appropriate answers for tattoos, acupuncture and body piercings.
 
Piercing How Many? Most Recent? Sterile Needles? Most Recent Performed by?
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Please provide locations of tattoos and piercings.
26. Please select the most accurate answers regarding question about your experience with the law.
 
Law Times Arrested Times Convicted Misdemeanors Felonies Days of Incarceration Most Recent Incarceration
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Please provide any additional information about convictions.
27. Please select the most accurate answers regarding question about your sexuality.
 
Sexuality Orientation Monogamous Current Partners Past 6 Months Past 3 Years Known STD's
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28. Are your currently breastfeeding?
 
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29. What kind of contraception do you use?
 














If "Other", please explain.
30. In the last 6 months, have you had a diagnosis of Zika virus?
 
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31. Have you taken a Depo Provero shot within the past year?
 
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32. In the last 6 months, have you lived in or traveled to an area that has been reported as a risk for the Zika virus?
 
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33. In the last 6 months, have you had sex with a man who has lived in or traveled to an area with active Zika virus?
 
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34. Do you have both ovaries?
 
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35. Please provide answers to the following questions related to your Pap Smear results.
 
Pap Smear Recent Pap Recent Results Previous Results
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Please provide additional information related to abnormal results.
36. Have you ever been told by a medical doctor that you were infertile and/or conceived with fertility treatments?
 
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If yes, please explain.
37. Have you tested positive for Chlamydia or Gonorrhea within the last year?
 
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38. Have you ever been seen by psychiatrist, psychologist, social worker, counselor, or any other medical health professional for any reason?
 
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If yes, when, for how long, for what reason.
39. Have you ever used medications such as antianxiety or antidepressants to treat an emotional or psychological problem?
 
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If yes, please list why and date last used.
40. Have you had a blood transfusion?
 
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If yes, when?
41. Have you ever been refused or denied as a blood donor?
 
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42. Are you adopted?
 
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43. Are there known genetic problems in your family?
 
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If yes, please explain.
44. Are there any members of your family with a history of learning disabilities or autism?
 
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If yes, please explain.
45. The following questions should only include information regarding the following relatives to: Yourself, Children, Mothers, Fathers, Siblings, Grandparents, Aunts & Uncles (not by marriage), and 1st Cousins.
 
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46. How many relatives has/had the following: BIRTH DEFECTS: Cleft Lip / Palate, Congenital Hip Problems, Club Feet, Heart Defect, Hearing Problems, Spina Bifida, Neural Tube (open spine), Microcephaly, Holoprosencehpaly, Other
 
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47. How many relatives has/had the following: : Down Syndrome, Turner, Fragile X, Klinefelter's, Other.
 
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48. How many relatives has/had the following: : Breast, Colon, Intestinal, Lung, Ovarian, Uterine, Prostate, Testicular, Skin, Stomach, Thyroid, Blood (e.g. leukemia), Other.
 
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49. How many relatives has/had the following: : Stroke, Heart Attack, Congenital Heart Disease, Heart Disease, Heart Defect, Hardening of the Arteries, High Blood Pressure ,High Cholesterol Level, Other.
 
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50. How many relatives has/had the following: REPRODUCTIVE: 2 or more Miscarriages, Stillborn, Premature Menopause, Death of a newborn infant, Childhood death, Birth Defects, Infertility, Premature Birth, Other.
 
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51. How many relatives has/had the following: GENITAL / REPRODUCTIVE: Low Sperm Count, Hermaphroditism, Ambiguous Genitals, Hypospadias, Undescended Testicle(s), Uterine Fibroids, Ovarian Cysts, Ruptured Lumps or Cysts in Breast, Discharge Polycystic, Ovarian Syndrome (PCOS), Pelvic Inflammatory Disease (PID), Endometriosis, Other.
 
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52. How many relatives have/had the following: NEUROLOGICAL: Migraines, Mental Retardation, Senility or Mental Deterioration before age 50, Multiple Sclerosis, Cerebral Palsy, Neurofibromatosis, Epilepsy / Seizures, Attention Deficit Disorder / Hyperactivity, Autism / Asperger's, Alzheimer's Disease, Dementia, Hydrocephalus, Tuberous Sclerosis, Parkinson's Disease, Creutzfeldt-Jakob Disease, Scoliosis, Myasthenia Gravis, Huntington's Disease, Wilson's Disease, Tourette's Syndrome, Other.
 
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53. Have you ever had sex for drugs or money in the past 5 years?
 
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54. How many relatives have/had the following: MENTAL HEALTH: Anxiety, Panic Attacks, Anorexia, Bulimia, Other eating disorders, Depression, Schizophrenia, Manic Depressive, Bipolar Disorder, Suicide Attempts, Other.
 
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55. How many relatives have/had the following: ADDICTION: Alcoholism, Drug Abuse, Drug Misuse, Drug Addict, Smoking, Gambling, Compulsive Behaviors, Other.
 
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56. Our organization uses a secure server for some email communication with you. The server is www.donorapplication.com. Email will come to you from no-reply@donorapplication.com. The domain of donorapplication.com needs to be acceptable to your spam filters to ensure email communication. (Google: "how to add an email address to safe list in (Outlook, Google, Yahoo, etc.)"
 
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57. What is your email address for communication with you regarding your pre-screen application?
   
57. Please verify your email address
   
58. What is your preferred password for future login reference?
   (6-20 characters with 4 or more letters and 1 or more numbers)  
59. Verify your password