Atlantic Reproductive Medicine Specialists
 

1. Today's Date
 
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2. Full Name
 
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3. City
 
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4. State
 
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5. Zip Code
 
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6. Primary Phone
 
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7. Primary Phone - OK to leave a message?
 
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8. Is it okay to send a text message on this number?
 
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9. Email Address
 
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10. Best way to contact you?
 

11. Date of Birth
 
   
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. How did you hear about this donor program?
 
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14. Are you able to travel to our clinic in Raleigh for screening without paid travel expenses?
 
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15. Are you prepared to spend an hour answering extensive questions regarding family history?
 
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16. Closest description of your race
 
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If multi-racial, please provide your closest description.
17. What race and/or ethnicity best represents you?
 








18. Do you have any Jewish ancestry?
 
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19. Is anyone in your family a registered member of a Native American tribe?
 
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20. Are you eligible to register with a Native American tribe?
 
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21. What is your age?
 
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22. Height
 
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23. Weight
 
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24. What is your natural eye color?
 
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25. What is your natural hair color?
 
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26. Years completed of high school:
 
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27. Years completed of college (undergraduate):
 
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28. Have you ever been hospitalized for psychiatric care, seen by a counselor, or been on medication?
 
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If yes, please explain.
29. Do you have chronic depression or anxiety (duration of 6 months or longer)?
 
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Please Explain
30. Are you currently on medications for anxiety, depression, or ADHD?
 
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Please Explain
31. Have you ever been on a prescription medication for more than 2 weeks in the last 3 years?
 
Rx Medication / Supplement Indication for Use Date Started Date Ended
1: Yes Yes Yes Yes
2: Yes Yes Yes Yes
3: Yes Yes Yes Yes
4: Yes Yes Yes Yes
5: Yes Yes Yes Yes
32. 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?
33. Do you consume alcoholic beverages?
 
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34. Have you ever been convicted of a crime?
 
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If yes, please explain.
35. Have you ever spent time in jail?
 
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If yes, please explain.
36. What is your marital status?
 
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37. What form of birth control are you currently using?
 
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38. How many total pregnancies have you had? (include miscarriages, abortions, stillbirths, and live births)
 
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39. Of these pregnancies, how many have resulted in a miscarriage?
 
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Please provide the date(s) of each miscarriage:
40. Of these pregnancies, how many have resulted in an abortion?
 
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Please provide the date(s) of each abortion:
41. Of these pregnancies, how many have resulted in a stillbirth?
 
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Please provide the date(s) of each stillbirth:
42. Of these pregnancies, how many resulted in a live birth?
 
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43. Are you currently breastfeeding?
 
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44. Are you adopted?
 
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45. Are there genetic or medical conditions that run in your family?
 
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If yes, please explain:
46. Please explain your motivation for becoming an egg donor.
 
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47. What is your email address for communication with you regarding your pre-screen application?
   
47. Please verify your email address
   
48. What is your preferred password for future login reference?
   (6-20 characters with 4 or more letters and 1 or more numbers)  
49. Verify your password
   


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