Abington Reproductive Medicine
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. How long will it take you to get to our office? (1245 Highland Avenue, Suite 404, Abington, PA 19001)
 
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5. 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).
6. Are you currently enrolled as an egg donor in another program?
 
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7. How many times have you donated your eggs?
 
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8. Which ethnicity would you most likely be affiliated?
 
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9. Date of Birth (only your calculated age is shared with Recipients)
 
   
10. What is your height?
 
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11. What is your weight in pounds?
 
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12. What is your highest level of completed education?
 
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13. Is your work schedule flexible?
 
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14. How many cigarettes do you smoke per day?
 
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15. When is the last time you had marijuana?
 
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16. How many drinks do you usually consume in a week?
 
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17. 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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18. When was the last time you have had a tattoo or body piercing?
 
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19. 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 for your application to be considered.
20. Have you ever had any arrests, convictions, sentences, etc.?
 
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If yes, please explainfor your application to be considered.
21. What is the most number of consecutive days that you have been incarcerated?
 
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If yes, please explain for your application to be considered.
22. How many current sexual partners do you have?
 
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23. How many sexual partners have you been with during the past 6 months?
 
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24. How many sexual partners have you been with in your lifetime??
 
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25. What kind of contraception do you use?
 













If "Other", please explain.
26. How many miscarriages have you had?
 
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27. How many ectopic pregnancies have you had?
 
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28. How many abortions have you had?
 
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29. How many stillbirths have you had?
 
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30. How many children have you given birth to?
 
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31. What is the longest length of time it took you or your partner to get pregnant? (in months)
 
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32. Are your currently breastfeeding?
 
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33. Do you have both ovaries?
 
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34. Are your menstrual periods regular (when not on the pill)?
 
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35. How long is your monthly cycle (first day of one period to first day of the next)?
 
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36. What is the date of your last Pap Smear?
 
   
37. What is the result of your last Pap Smear?
 
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38. Have you ever been told by a medical doctor that you were infertile?
 
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If yes, please explain.
39. Are you currently under a physicians care for any reason?
 
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If yes, please explain for your application to be considered
40. Have you ever had any complications or concerns with anesthesia?
 
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If yes, please explain.
41. 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 for your application to be considered
42. 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 for your application to be considered
43. Have you ever taken anti-malarial drugs or had malaria?
 
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44. Have you had a blood transfusion?
 
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45. Have you ever been refused or denied as a blood donor?
 
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46. Are you adopted?
 
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47. How many immediate family members have alcohol or drug abuse? (parents, self, siblings, or children)
 
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48. How did you hear about our program?
 









Please provide any addition details.
49. What is your email address for communication with you regarding your pre-screen application?
   
49. Please verify your email address
   
50. What is your preferred password for future login reference?
   (6-20 characters with 4 or more letters and 1 or more numbers)  
51. Verify your password