1. Are you a US citizen or permanent resident?
 
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2. Are you eligible to work in the United States?
 
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3. What is your FIRST name?
 
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4. City
 
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5. State
 
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6. 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).
7. Are you currently enrolled as an egg donor in another program?
 
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8. How many times have you donated your eggs?
 
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9. What race would you most likely be affiliated?
 
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10. What is your date of birth?
 
   
11. What is your height?
 
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12. What is your weight?
 
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13. What is your highest level of completed education?
 
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14. Is your work schedule flexible?
 
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15. How many cigarettes do you smoke per day?
 
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16. When is the last time you had marijuana?
 
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17. How many drinks do you usually consume in a week?
 
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18. When is the last time you have used recreational or illicit drugs (cocaine, LSD, heroin, barbiturates, narcotics, opiates, amphetamines, hallucinogens, tranquilizers, PCP, steroids for non-medical reasons, or etc.)?
 
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19. Have you had acupuncture, ear and/or body piercings or tattooing on your body?
 
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20. When was the last time you have had a tattoo or body piercing?
 
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21. If a background check were run on you, would it show any problems with the law (i.e. DUI, custody issues, lawsuits)?
 
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If yes, please explain.
22. Have you ever had any arrests, convictions, sentences, etc.?
 
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If yes, please explain.
23. What is the most number of consecutive days that you have been incarcerated?
 
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24. How many current sexual partners do you have?
 
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25. How many sexual partners have you been with during the past 6 months?
 
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26. How many sexual partners have you been with in your lifetime??
 
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27. In the last 6 months have you had unprotected sex (intercourse without a condom) with a new partner?
 
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28. What kind of contraception do you use?
 













If "Other", please explain.
29. How many pregnancies have you had?
 
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30. How many miscarriages have you had?
 
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31. How many ectopic pregnancies have you had?
 
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32. How many abortions have you had?
 
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33. How many stillbirths have you had?
 
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34. What is the longest length of time it took you or your partner to get pregnant? (in months)
 
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35. Are your currently breastfeeding?
 
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36. Do you have both ovaries?
 
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37. What was your age at the onset of menses?
 
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38. Are your menstrual periods regular (when not on the pill)?
 
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39. How long is your monthly cycle (first day of one period to first day of the next)?
 
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40. How many days does your period usually last?
 
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41. What is the result of your last Pap Smear?
 
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Please provide additional information for "Abnormal".
42. Have you ever been told by a medical doctor that you were infertile?
 
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If yes, please explain.
43. Have you recently experienced weight loss or weight gain?
 
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Please explain any reason for weight changes.
44. Have you ever had any complications or concerns with anesthesia?
 
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If yes, please explain.
45. 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.
46. Have you been vaccinated in the past 6 months (excluding a flu shot)?
 
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If yes, what were you vaccinated for?
47. 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.
48. Have you ever taken anti-malarial drugs or had malaria?
 
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49. Have you had a blood transfusion?
 
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If yes, when, what country and why?
50. Have you ever been refused or denied as a blood donor?
 
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51. Have you had radiation exposure or x-ray exposure?
 
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Please explain.
52. Are there known genetic problems in your family?
 
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If yes, please explain.
53. Do you have any brothers or sisters that died in infancy or childhood?
 
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If yes, what was the cause?
54. Are there any members of your family with a history of learning disabilities or autism?
 
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If yes, please explain.
55. Are you adopted?
 
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56. What is your email address for communication with you regarding your pre-screen application?
   
57. What is your preferred password for future login reference?
   (6-20 characters with 4 or more letters and 1 or more numbers)  
58. Verify your password.
   

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