1. First Name
 
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2. Last Name
 
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3. Current Address
 
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4. Closest Major Metropolitan Area
 
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5. What is your Phone Number?
 
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6. Date of Birth
 
   
7. How did you hear about our Egg Donor Program?
 





If you chose College Advertisement, please specify which school.
8. Do you have previous egg donation experience?
 
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9. What is your Ethnicity? (German, Irish, French, Indian, etc.)
 
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10. What race do you most affiliate yourself with? (Caucasian, Hispanic, Asian, Pacific Islander, etc)
 
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11. Are You of Jewish or Asian Descent?
 


12. What type of egg donation arrangement do you wish to have with the Intended Parents? (Check ALL that you feel comfortable working in)
 


13. Please check all the types of Intended Parents to whom you are NOT willing or comfortable donating.
 








14. Are you willing to travel to donate your eggs? (Reimbursement for travel expenses provided)
 
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15. Were you born in the United States?
 
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16. If answered No, please supply the City and Country.
 
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17. Number of Children
 
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18. Marital Status
 
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19. Have you ever lived or traveled outside of the United States?
 
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If so, where did you go and how long were you there?
20. Blood type and Rh Factor
 
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21. What form of birth control are you currently using?
 
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22. Which answer describes your current situation related to HIV?
 
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23. Do you smoke tobacco daily?
 
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24. Have you ever smoked Marijuana?
 
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25. Have you ever used any other illegal drugs?
 
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26. Height
 
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27. Weight
 
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28. Eye Color
 
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29. Natural Hair Color
 
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30. Complexion
 
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31. Tanning Ability
 
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32. Physical Build
 
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33. Hair Texture
 
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34. Predominant Hand
 
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35. Do you have any health problems you need to disclose? (EX:Hep. B, Asthma, Heart Condition, etc.)
 
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If yes, please describe.
36. Have you had any plastic surgery?
 
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If so, what type of surgery and when?
37. Have you had any reconstructive surgery?
 
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If so, what kind of reconstructive surgery and when?
38. Have you had any corrective surgery?
 
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If so, what kind of corrective surgery and when?
39. Do you or any of your immediate relatives have any birth defects?
 
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Please provide the relation to the relatived and the nature of the deformity.
40. Have you or any relatives in your immediate family had a heart attack? Enter "NA" in the first box if no one has had a heart attack.
 
Heart Attack Yes No Don't Know
Self: Yes Yes Yes
Maternal Grandmother: Yes Yes Yes
Maternal Grandfather: Yes Yes Yes
Paternal Grandmother: Yes Yes Yes
Paternal Grandfather: Yes Yes Yes
Mother: Yes Yes Yes
Father: Yes Yes Yes
Sibling 1: Yes Yes Yes
Sibling 2: Yes Yes Yes
Sibling 3: Yes Yes Yes
Sibling 4: Yes Yes Yes
Child 1: Yes Yes Yes
Child 2: Yes Yes Yes
Child 3: Yes Yes Yes
Child 4: Yes Yes Yes
41. Have you or any of your immediate family members had a stroke?
 
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Please provide the relative and the age of the stroke.
42. Have you or any of your relatives had deafness?
 



If yes to any of the above, please provide the relative and whether deafness was from birth, childhood or as an adult.
43. Have you or anyone in your immediate family had any form of cancer?
 
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If so, please provide the relative (or self) and the type of cancer.
44. Are you on any prescribed medication? If so please list all medication and why you are taking it.
 
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45. Which answer best describes your highest level of completed education?
 
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46. Did you take the ACT or SAT?
 
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47. Grade Point Average
 
Grades / Scores GPA / Scores
High School GPA:  
College GPA (current or complete):  
Major (where appropriate):  
ACT Composite Score:  
SAT Score:  
48. Would you be willing to take an intelligence (IQ) test if requested?
 
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If you have already been tested, what was your score?
49. At what age did your periods begin?
 
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50. Do you have a cycle every month?
 
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51. How many days between cycles? (beginning of one cycle to the beginning of the next)
 
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52. Do you have both ovaries?
 
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53. How long have you been using birth control?
 
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54. When was your last PAP smear?
 
   
55. Do you have your tubes tied?
 
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56. Do you have or have had Ovarian Cancer?
 
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57. Do you have or have you ever had any Sexually Transmitted Diseases?
 
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If so, please list the STD, what year you had it, and if you were treated and cleared (also include year of treatment).
58. Do you have any Ob/Gyn conditions you need to disclose?
 
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If yes, please provide the additional information.
59. How many premature births?
 
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60. How many still births?
 
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61. How many times have you had a miscarriage?
 
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62. How many times have you had a cesarean section?
 
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63. Did you use any medical intervention to help conceive your children (including treatment for infertility)?
 
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If yes, please explain the medical intervention.
64. Are you currently employed?
 
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If so, what do you do for a living? (Do not include identifying information, including your employer).
65. If compensated, are you willing to travel for ALL necessary medical treatment?
 
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66. Due to HIPAA laws in the state of California, if you test POSITIVE for any illegal drug, you will be prohibited from being an Egg Donor in the state of California and will be responsible to pay for your Medical Screening.
 
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67. Once I am selected as an Egg Donor, I understand and agree that the recipients of my eggs or embryos created with my eggs, have full decision making capability on how the embryos are used. This may include storage, further donation to another third party, stem cell research or destroying them.
 
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68. I understand and accept that I will be providing Surrogate Alternatives, Inc. photos of myself that will be shown to Intended Parents on a secure server through a password protected environment.
 
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69. What is your email address for communication with you regarding your pre-screen application?
   
70. What is your preferred password for future login reference?
   (6-20 characters with 4 or more letters and 1 or more numbers)  
71. Verify your password.
   

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