Heartland Center for Reproductive Medicine
1. FIRST name
 
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2. LAST name
 
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3. Street Address, Apartment #
 
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4. City
 
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5. State
 
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6. Zip Code
 
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7. Based on the following address: (7308 South 142nd Street Omaha, NE 68138) ... how much time will it take to get to this location? (typical treatment cycle is 11 visits)
 
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8. What is the primary phone number (include area code) to use for contact and leaving messages?
 
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9. What is your marital / relationship status?
 
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10. Please select the most accurate response to your eligibility to work in the USA, your residency, and your citizenship.
 
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Please enter your country of birth, any information related to "not" being a permanent resident, and/or non-citizen credentials to be able to legally work.
11. Please select the most accurate response to your experience in donating your eggs.
 
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Please provide any information related to your previous applications and/or donations whether they were with our organization or not.
12. Closest description of your race. Note: Combinations of multi-racial descriptions are only in 1 menu. For example, "Black and Latin/Hispanic" is not listed in "Latin/Hispanic and Black" since they are the same.
 
If any racial descriptions include "Other", please explain.
13. What is your date of birth?
 
   
14. Height
 
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15. Weight
 
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16. What is your eye color?
 
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17. What is your natural hair color?
 
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18. What is your highest level of completed education?
 
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19. Did you have any learning disabilities or significant weaknesses in school that required professional attention?
 
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If yes, describe.
20. Is your work schedule flexible?
 
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21. Have you completed egg donation cycles that have resulted in a pregnancy?
 
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22. Please select the best answer related to smoking habits (including any form of nicotine products, including e-cigarettes).
 
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Donating eggs will require no smoking and this will be tested. If you smoke, are you willing to quit?
23. What period of time did you use tobacco products (ie: 6 months, 2 years, 5 years, etc)?
 
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24. When is the last time you had marijuana?
 
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25. When is the last time you have used other recreational drugs such as: Cocaine, Barbituates, Narcotics, Opiates, Amphetamines, Hallucinogens, Tranquilizers (non-medical), PCP, Inhalants, Steroids (non-medical), Ecstacy, or other recreational drug for NON-MEDICAL purposes?
 
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Please provide the name of the drug.
26. What date was the last time you used marijuana/recreational drugs?
 
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27. What is the most number of consecutive days that you have been incarcerated?
 
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28. 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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29. 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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30. Please provide information related to your children or enter in the first box a check if you don't have any children.
 
Your Children 0 1 2 3 4 5
Wears Eye Glasses?: Yes Yes Yes Yes Yes Yes
Discipline Problems?: Yes Yes Yes Yes Yes Yes
Any Medication?: Yes Yes Yes Yes Yes Yes
Dyslexia?: Yes Yes Yes Yes Yes Yes
Reading Difficulties?: Yes Yes Yes Yes Yes Yes
Speech Difficulties?: Yes Yes Yes Yes Yes Yes
Any special services at school?: Yes Yes Yes Yes Yes Yes
Seen by Social Worker/Psychiatrist?: Yes Yes Yes Yes Yes Yes
31. Are your currently breastfeeding?
 
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32. What kind of contraception do you currently use?
 













If "Other", please explain.
33. Why did you start taking birth control pills?
 
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Please explain "Other"
34. Have you taken a Depo Provero shot within the past year?
 
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35. Do you have both ovaries?
 
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36. Please provide information related to your reproductive cycle.
 
Cycle Age Started Period Are Cycles Regular Total Cycle Length Days of Menses Medication for Pain
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37. 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.
38. Have you ever had a pelvic infection requiring treatment with antibiotics?
 
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If yes, please explain.
39. Have you ever been treated for any gynecologic problems such as cysts, fibroids, or endometriosis?
 
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If yes, please explain.
40. Have you tested positive for Chlamydia or Gonorrhea within the last year?
 
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41. Have you ever had any of the following?
 











Please list the last time and how many times where appropriate.
42. Have any of your partners ever had any of the following?
 














Please provide additional information where appropriate.
43. How is your vision (without corrective lenses or surgery)?
 
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What is your prescription (if known)?
44. How is your hearing (without corrective aids)?
 
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45. Do you have allergies?
 

















Please explain.
46. What type of allergies do you currently have?
 
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Please Explain
47. For each medication allergy, describe specific substance and reaction(s) and age first diagnosed. (or enter "N/A")
 
Medication Allergy Substance Reaction(s) Age Diagnosed
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48. List all medications that you have taken in the proceeding 12 months (prescription).
 
Medications Medication How Often Reason
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49. Are you currently under a physicians care for any reason?
 
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If yes, please explain.
50. Have you had any serious illness in the past that may have resulted in hospitalization or the threat of hospitalization?
 
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If yes, describe.
51. Have you had any surgical procedures, other than broken bones, dental, tubal ligation or c-section?
 
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If yes, please list procedure and date.
52. Have you had any hospitalization(s) not mentioned above and not related to giving birth?
 
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Please Explain
53. Are you adopted?
 
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54. Are there known genetic problems in your family?
 









If yes, please explain.
55. What is your email address for communication with you regarding your pre-screen application?
   
55. Please verify your email address
   
56. What is your preferred password for future login reference?
   (6-20 characters with 4 or more letters and 1 or more numbers)  
57. Verify your password