Fertility Center of Oregon
 

1. Are you eligible to work in the United States?
 
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2. Are you a US citizen or permanent resident?
 
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3. FIRST name
 
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4. Based on the following address: (590 Country Club Parkway, Eugene, OR 97401 ) ... how much time will it take to get to this location? (typical treatment cycle is 6-8 visits)
 
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5. What is the primary phone number (include area code) to use for contact and leaving messages?
 
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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. Closest description of your race
 
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If multi-racial, please provide your closest description.
10. What is your date of birth?
 
   
11. Height
 
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12. Weight (please be accurate-we want your current weight)
 
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13. What is the best description of your level of 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. How many drinks do you usually consume in a week?
 
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17. If a background check were run on you, would it show any significant problems with the law (i.e. theft, fraud, violence, possession of drugs, DUI, custody issues, lawsuits)?
 
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If yes, please explain.
18. What is the most number of consecutive days that you have been incarcerated?
 
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19. What kind of contraception (birth control) do you use?
 


















If "Other", please explain.
20. Do you or one of your partners in the last 5 years have HIV, Hepatitis B or C, or has been an IV (intravenous) drug user?
 
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21. Have you taken a Depo Provero shot within the past year?
 
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22. Are your currently breastfeeding?
 
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23. Do you have both ovaries?
 
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24. What was your age at the onset of menses?
 
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25. Are your menstrual periods regular (when not on the pill)?
 
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26. How long is your monthly cycle (first day of one period to first day of the next)? Choose the option that best describes your cycle.
 
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27. Have you ever been told by a medical doctor that you were infertile, or have you used fertility treatments to get pregnant?
 
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If yes, please explain.
28. Have you tested positive for Chlamydia or gonorrhea within the last year?
 
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29. Have you ever been seen by psychiatrist, psychologist, social worker, counselor, or any other mental health professional for any reason?
 
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If yes, when, for how long, for what reason.
30. 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.
31. Are you adopted?
 
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32. 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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33. Is there anything else you would like to share with us regarding your pre-screen application?
 
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34. What is your email address for communication with you regarding your pre-screen application?
   
34. Please verify your email address
   
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