Atlantic Reproductive Medicine Specialists
 

1. Today's Date
 
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2. Full Name
 
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3. Email Address
 
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4. City
 
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5. State
 
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6. Primary Phone
 
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7. What is your age? Please enter your date of birth.
 
   
8. Height
 
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9. Is it okay to send a text message on this number?
 
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10. Weight
 
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11. Closest description of your race
 
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If multi-racial, please provide your closest description.
12. Are you able to provide detailed information about your relatives on both your maternal and paternal sides of the family including parents, siblings, grandparents, aunts, and uncles?
 
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Please Explain
13. Are you prepared to spend an hour answering extensive questions regarding family history?
 
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14. Have you spent 3 months or more, cumulatively, in the UK (England, Northern Ireland, Scotland, Wales, the Isle of Man, the Channel Islands, Gibraltar, or the Falkland Islands) from the beginning of 1980 through the end of 1996?
 
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15. Are you able to travel to our clinic in Raleigh for screening without paid travel expenses?
 
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16. Is anyone in your family a registered member of a Native American tribe?
 
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17. Years completed of high school:
 
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18. Are you eligible to register with a Native American tribe?
 
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19. Have you ever been hospitalized for psychiatric care, seen by a counselor, or been on medication?
 
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If yes, please explain.
20. Do you have chronic depression or anxiety (duration of 6 months or longer)?
 
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Please Explain
21. Are you currently on medications for anxiety or depression?
 
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22. Do you use nicotine products (i.e. cigarettes, e-cigarettes, nicotine gum, etc.)?
 
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If yes, how many do you use per week?
23. Are you currently breastfeeding?
 
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24. Are you adopted?
 
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25. Are there genetic or medical conditions that run in your family?
 
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If yes, please explain:
26. How did you hear about this donor program?
 
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27. What is your email address for communication with you regarding your pre-screen application?
   
27. Please verify your email address
   
28. What is your preferred password for future login reference?
   (6-20 characters with 4 or more letters and 1 or more numbers)  
29. Verify your password
   


© 2018 - Atlantic Reproductive Medicine Specialists
10208 Cerny Street, Suite 306 • Raleigh, NC 27617 • Call 919.328.2956