PERSONAL INFORMATION

Age:

Age:

Location:

Slovakia

Nationality:

Slovakian

Hair color:

blonde

Eye color:

green

Height:

Feet

Inches

Weight:

113

BMI index:

20

Previous donor:

No

Proven donor(pregnancies/live births):

Previous own pregnancies:

No

Blood type:

unknown

Talent/Interest:

Hair styling

Current level of education:

Master degree

Why would like to become an egg donor?

Help others

What would you like to say to the future recipients of your eggs?:

Good luck!

Nationality:

Slovakian

Nationality of mother:

slovakian

Nationality of father:

slovakian

Religion(born to/chosen):

None

Allergies:

tomatos,kiwi....,

Hair color in childhood:

Straight

Boldness:

No

Boldness in family:

No

Premature greying(when):

No

Skin complexion(fair/medium/olive/dark):

normal

Skin condition(dry/oily/combination/normal):

Age:

Tanning ability(none/easy/medium/freckle):

Easy

Bone structure(small/medium/large):

Middle

Facial features(mala, stredna,velka):

Middle

Dominant hand(left/right):

Right

Vision(glasses/contacts/laser surgery/none):

Good

Hearing w/o corrective aids(poor/fair/god/excellent):

Good

Teeth(poor/fair/god/excellent)+in childhood:

Periodontal/orthodontic work:

Age:

ACADEMICS:

Level of education:

Age:

Speciality:

Age:

Difficulties/disabilities in learning/reading/writing:

Age:

Academic strengths (math, reading...):

Age:

Academic rewards/appreciations:

Age:

Career goals:

Age:

Personal goals:

Age:

Which of these goals did you achieve as of now?

Age:

Ans

PERSONALITY TRAITS:

Hobbies:

Age:

Artistic abilities (musical, painting…):

Age:

Sports/athletics:

Age:

Favorite subject in school:

Age:

Favorite books:

Age:

Favorite movies:

Age:

How would you describe your personality?

Age:

What is your best personality trait?

Age:

What is your most unique quality?

Age:

Describe yourself as a child:

Age:

What did your parents teach you to value?

Age:

Is there anybody(dead or alive) whom you admire and why?

Age:

Who was the most important influence on you and why?

Age:

MEDICAL:

Do you have any medical condition?Serious illness in the past(blood clots, pneumonia, mononucleosis?When?

Age:

Are you currently on any medications?

Age:

List any  medications you have taken over last 5 years:

Age:

Have you ever had any surgeries?

Age:

Did you have any complications with anesthesia?

Age:

Have you ever been hospitalized? Why? When?

Age:

Has anyone in your family, including yourself, experienced recurring and/or chronic symptoms that have not been evaluated by a physician (Please included symptoms that you may not consider serious.)?

Age:

How many days in the preceding 12 months did you miss work because of illness

(colds, flu, accidents, surgery, etc.)??

Age:

Are your menstrual periods regular??

Age:

How long is your monthly cycle (first day of one period to first day of the next)?

Age:

days?

Age:

How long is the your period?

Age:

Have you ever had any medical treatment for menstrual problems?

Age:

Have you ever been seen by psychiatrist, psychologist, social worker, counselor, or any other mental health professional for any reason?

Age:

If yes, when, for how long and for what reason?

Age:

Have you ever used medications such as antianxiety or antidepressants to treat

an emotional or psychological problem?

Age:

If yes, list why and date last used::

Age:

Have you been vaccinated in the last 6 months?

Age:

Have you ever taken anti-malarial drugs or had malaria?

Age:

Have you had a blood transfusion?

Age:

Have you ever been refused or denied as a blood donor?

Age:

Have you ever been exposed to “agent orange” or any other herbicides or chemicals (military, forestry, highway service, or elsewhere)? If so – when?where?

Age:

Have you had a tattoo or piercing within the last 6 months?

Age:

Do you smoke? If yes, how often?

Age:

Do you drink? If yes, how often?

Age:

What is your caffeine usage? Number cups of coffee:

Age:

Soda 

Age:

Tea

Age:

Energy Drink

Age:

Have you used recreational drugs (you will be tested)?

Age:

If yes, please explain:

Age:

Do you sleep well?

Age:

If no, how do you manage this?

Age:

Are you sexually active?

Age:

If yes, what form of birth control do you use?

Age:

How many sexual partners have you had in the past year?

Age:

Have you or any of your sexual partners been in contact with anyone or have you been personally tested or been treated for any sexually transmitted diseases (HIV, NSU, syphilis, gonorrhea, etc.)?

Age:

If so, you or your partner, please explain:

Age:

FAMILY MEMBERS:

Father

Age (living):

Age:

Age (time of death):

Age:

Cause of Death:

Age:

Weight:

Age:

Height:

Age:

Bone Structure:

Age:

Hair Color:

Age:

Eye Color:

Age:

Complexion:

Age:

Mother

Age (living):

Age:

Age (time of death):

Age:

Cause of Death:

Age:

Weight:

Age:

Height:

Age:

Bone Structure:

Age:

Hair Color:

Age:

Eye Color:

Age:

Complexion:

Age:

Paternal Grandfather

Age (living):

Age:

Age (time of death):

Age:

Cause of Death:

:

Weight:

Age:

Height:

Age:

Bone Structure:

Age:

Hair Color:

Age:

Eye Color:

Age:

Complexion:

Age:

Paternal Grandmother

Age (living):

Age:

Age (time of death):

Age:

Cause of Death:

Age:

Weight:

Age:

Height:

Age:

Bone Structure:

Age:

Hair Color:

Age:

Eye Color:

Age:

Complexion:

Age:

Maternal Grandfather

Age (living):

Age:

Age (time of death):

Age:

Cause of Death:

Age:

Weight:

Age:

Height:

Age:

Bone Structure:

Age:

Hair Color:

Age:

Eye Color:

Age:

Complexion:

Age:

Maternal Grandmother

Age (living):

Age:

Age (time of death):

Age:

Cause of Death:

Age:

Weight:

Age:

Height:

Age:

Bone Structure:

Age:

Hair Color:

Age:

Eye Color:

Age:

Complexion:

Age:

Sibling 1:

Gender:

Age:

Age (living):

Age:

Age (time of death):

Age:

Cause of Death:

Age:

Weight:

Age:

Height:

Age:

Bone Structure:

Age:

Hair Color:

Age:

Eye Color:

Age:

Complexion:

Age:

Sibling 2:

Gender:

Age:

Age (living):

Age:

Age (time of death):

Age:

Cause of Death:

Age:

Weight:

Age:

Height:

Age:

Bone Structure:

Age:

Hair Color:

Age:

Eye Color:

Age:

Complexion:

Age:

Sibling 3:

Gender:

Age:

Age (living):

Age:

Age (time of death):

Age:

Cause of Death:

Age:

Weight:

Age:

Height:

Age:

Bone Structure:

Age:

Hair Color:

Age:

Eye Color:

Age:

Complexion:

Age:

Sibling 4:

Gender:

Age:

Age (living):

Age:

Age (time of death):

Age:

Cause of Death:

Age:

Weight:

Age:

Height:

Age:

Bone Structure:

Age:

Hair Color:

Age:

Eye Color:

Age:

Complexion:

Age:

Child 1:

Gender:

Age:

Age (living):

Age:

Age (time of death):

Age:

Cause of Death:

Age:

Weight:

Age:

Height:

Age:

Bone Structure:

Age:

Hair Color:

Age:

Eye Color:

Age:

Complexion:

Age:

Child 2

Gender:

Age:

Age (living):

Age:

Age (time of death):

Age:

Cause of Death:

Age:

Weight:

Age:

Height:

Age:

Bone Structure:

Age:

Hair Color:

Age:

Eye Color:

Age:

Complexion:

Age:

Mother's Occupation:

Age:

Mother's level of education:

Age:

Describe your mother's personality:

Age:

Father's Occupation:

Age:

Father's level of education:

Age:

Describe your father's personality:

Age:

Paternal Grandfather's Occupation:

Age:

Paternal Grandfather's level of education:

Age:

Describe your paternal grandfather's personality:

Age:

Paternal Grandmother's Occupation:

Age:

Paternal Grandmother’s level of education:

Age:

Describe your paternal grandmother’s personality:

Age:

Maternal Grandfather’s Occupation:

Age:

Maternal Grandfather’s level of education:

Age:

Describe your maternal grandfather’s personality:

Age:

Maternal Grandmother’s  Occupation:

Age:

Maternal Grandmother’s level of education:

Age:

Describe your maternal grandmother’s personality:

Age:

Sibling 1 Occupation:

Age:

Sibling 1  level of education:

Age:

Describe your Sibling 1 personality:

Age:

Number of children?

Age:

Sex of children?

Age:

Personalities?

Age:

Sibling 2 Occupation:

Age:

Sibling 2  level of education:

Age:

Describe your Sibling 2 personality:

Age:

Number of children?

Age:

Sex of children?

Age:

Personalities?

Age:

Sibling 3 Occupation:

Age:

Sibling 3  level of education:

Age:

Describe your Sibling 3 personality:

Age:

Number of children?

Age:

Sex of children?

Age:

Personalities?

Age:

Sibling 4 Occupation:

Age:

Sibling 4  level of education:

Age:

Describe your Sibling 4 personality:

Age:

Number of children?

Age:

Sex of children?

Age:

Personalities?

Age:

Child 1 personality and special skills:

Age:

Child 2 personality and special skills:

Age:

How many blood siblings are in your immediate family (including yourself and half siblings)?

Number of Brothers

Age:

Number of Sisters

Age:

Number of Maternal Uncles

Age:

Number of Maternal Aunts

Age:

Number of Paternal Uncles

Age:

Number of Paternal Aunts

Age:

Any brothers or sisters that died in infancy or childhood?

Age:

If yes, what was the cause?

Age:

Do any members of your family have a history of learning disabilities or autism?

Age:

If yes, please explain:

Age:

GENETIC HISTORY

PGF=Paternal Grandfather

PGM=Paternal Grandmother

MGF=Maternal Grandfather

MGM=Maternal Grandmother

RACE

African American

Jewish

Mediterranean

Hispanic

Indian (India)

Southeast Asian

French Canadian

Cajun

Have you or anyone in your family ever been tested positive as a carrier or had any of the following diseases?

Blooms Syndrome Canavan

Age:

Cystic Fibrosis Fabry Disease No

Age:

Familial Dysautonia

Age:

Fanconi Anemia

Age:

Gaucher

Age:

Niemann-Pick A

Age:

Mucolipidosis

Age:

Sickle Cell

Age:

Tay-Sachs

Age:

Thalassemia

Age:

Is there anything else we should know about your family?

Age:

Age:

PERSONAL AND FAMILY MEDICAL HISTORY

Including egg donor, mother, father, siblings, grandparents, aunts, uncles and cousins)

Current allergies (food, pollen, bee stings, medications, etc.):

Age:

Childhood allergies outgrown:

Age:

Medical illnesses, such as asthma, diabetes, seizure disorders, etc.?

Age:

Do you have astigmatism (blurred vision due to an irregularity in the curvature of the cornea)?

Age:

If yes, age diagnosed:

Age:

Do you have any dietary restrictions?

Age:

Cancer

(including breast, colon or intestinal, lung, ovarian or uterine, prostate or testicular, skin,stomach, thyroid, blood (e.g. leukemia), other)

Age:

Heart

(including stroke, heart attack, heart disease, hardening of arteries, high blood pressure,high cholesterol level):

Age:

Blood

(including anemia, sickle-cell anemia, hemophilia or other bleeding problem, blood clots or strokes, leukemia, immune deficiency, lymphoma, HIV, thalassemia, polyarteritis nodosa, other blood disorders):

Age:

Respiratory

(including hay fever, asthma, emphysema, tuberculosis, lung cancer, pneumonia, cystic fibrosis, other lung diseases):

Age:

Gastro-intestinal

(including appendicitis, ulcer of stomach or duodenum, gall stones, hepatitis A (infectious), hepatitis B (serum), hepatitis C, cirrhosis of the liver, hemochromatosis, other liver diseases, colon cancer, ulcerative colitis, Crohn's disease, pyloric stenosis, rectal disorder, multiple polyps of the colon, inflammatory bowel disease, cystic fibrosis, intestinal cancer, any other problem of the digestive system):

Age:

Metabolic/Endocrine

(including diabetes mellitus, childhood diabetes, hypoglycemia, thyroid cancer, thyroiddisease, goiter, adrenal dysfunction or disorder, metabolism disorder, hyperactivity, obesity, dwarfism):

Age:

Urinary

(including kidney disease, diseases of urinary tract (urethra, bladder, ureter), rectal disorder,

polycystic kidneys, kidney stones):

Age:

Genital/Reproductive

(including uterine fibroids, hermaphroditism/ambiguous genitals, undescended testicle, Hypospodiasis , prostate cancer, ovarian cysts, cancer of ovaries, pelvic inflammatory disease, endometriosis, breast cancer, multiple miscarriages, stillbirths, childhood deaths):

Age:

Reproductive Outcomes

(including 2 or more miscarriages, stillborn, premature menopause, death of a newborn infant, childhood death, birth defects, infertility, premature birth):

Age:

Neurological

(including migraines, mental retardation, senility before age 50, multiple sclerosis, cerebral palsy, multiple sclerosis, epilepsy, ADD/hyperactivity, autism / asperger’s, hydrocephalus, tuberous sclerosis, disorder of spinal cord, Huntington's chorea, Gaucher's disease, myasthenia gravis, Wilson's disease, Creutzfeldt-Jacob disease, Alzheimer's disease, Parkinson’s disease, neurofibromatosis, scoliosis, Tay Sachs, Canavan disease, tourette’s syndrome, other diseases of nervous system):

Age:

Mental Health

(including anxiety/panic attacks, anorexia/bulimia/other eating disorders, schizophrenia, manic depressive, bipolar disorder, alcoholism, drug abuse/misuse/addiction, depression, suicide/attempted suicide, nervous breakdown, mental retardation, criminal convictions or other disorders requiring hospitalization):

Age:

Muscular/Bones/Joints

(including muscular dystrophy, lupus, deformity of spine, osteoporosis, dwarfism growth problem, brittle bones, loss of muscle coordination, marfan syndrome, rheumatoid or juvenile arthritis, spinal muscular atrophy, hereditary low back disease/scoliosis, arthritis, gout, Lupus, Reiter’s disease, myasthenia gravis, other chronic muscle disease):

Age:

Sight/Smell/Sound

(including deafness before age 60, deformity of the ear, cataracts before age 50, blindness,

color blindness, severe myopia, glaucoma, retinoblastoma, retinitis pigmentosa, deviated

septum, any other disorders):

Age:

Skin

(including acne, albinism eczema, skin cancer, excessive facial hair (Hirsutism), pigmentation disorders, psoriasis, neurofibromatosis, infectious skin disease, other skin disorders):

Age:

Congenital Abnormalities/Birth Defects

(including cleft lip/palate, congenital hip problems, club feet, heart defect, hearing problems, Spina Bifida (open spine), microcephaly, holoprosencehpaly, other):

Age:

Chromosomal Abnormalities

(including down syndrome, Turner, Fragile X, other):

Age:

Other

(including alcoholism, drug abuse/misuse/addiction, premature degeneration of any organ system, any other condition):

Age:

Any other conditions not listed?

Age:

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