1. First Name
 
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2. At what age did your periods begin?
 
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3. Do you have a cycle every month?
 
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4. Which answer best describes your highest level of completed education?
 
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5. Marital Status
 
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6. Last Name
 
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7. 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?
8. Number of Children
 
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9. 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.
10. How many days between cycles? (beginning of one cycle to the beginning of the next)
 
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11. Did you take the ACT or SAT?
 
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12. Do you have both ovaries?
 
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13. Grade Point Average
 
Grades / Scores GPA / Scores
High School GPA:  
College GPA (current or complete):  
Major (where appropriate):  
ACT Composite Score:  
SAT Score:  
14. Eye Color
 
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15. Have you had any plastic surgery?
 
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If so, what type of surgery and when?
16. What is your Phone Number?
 
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17. Blood type and Rh Factor
 
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18. 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?
19. Current Address
 
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20. How long have you been using birth control?
 
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21. What form of birth control are you currently using?
 
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22. Have you had any reconstructive surgery?
 
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If so, what kind of reconstructive surgery and when?
23. Natural Hair Color
 
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24. When was your last PAP smear?
 
   
25. Closest Major Metropolitan Area
 
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26. Have you had any corrective surgery?
 
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If so, what kind of corrective surgery and when?
27. Which answer describes your current situation related to HIV?
 
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28. Date of Birth
 
   
29. Do you have your tubes tied?
 
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30. Complexion
 
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31. 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.
32. Do you smoke tobacco daily?
 
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33. Do you have or have had Ovarian Cancer?
 
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34. Height
 
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35. Have you ever smoked Marijuana?
 
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36. 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
37. Have you ever used any other illegal drugs?
 
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38. Weight
 
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39. 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.
40. 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).
41. 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.
42. Do you have any Ob/Gyn conditions you need to disclose?
 
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If yes, please provide the additional information.
43. Tanning Ability
 
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44. 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.
45. How many premature births?
 
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46. Physical Build
 
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47. How many still births?
 
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48. Hair Texture
 
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49. How many times have you had a miscarriage?
 
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50. What is your Ethnicity? (German, Irish, French, Indian, etc.)
 
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51. What race do you most affiliate yourself with?
 
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52. How many times have you had a cesarean section?
 
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53. 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.
54. Are You of Jewish or Asian Descent?
 


55. Do you have previous egg donation experience?
 
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56. Predominant Hand
 
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57. What type of egg donation arrangement do you wish to have with the Intended Parents? (Check ALL that you feel comfortable working in)
 


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








59. 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).
60. Are you willing to travel to donate your eggs? (reimbursement for travel expenses provided)
 
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61. If compensated, are you willing to travel for ALL necessary medical treatment?
 
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62. 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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63. 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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64. 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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65. What is your email address for communication with you regarding your pre-screen application?
   
66. What is your preferred password for future login reference?
   (6-20 characters with 4 or more letters and 1 or more numbers)  
67. Verify your password.
   

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