Donor

Name ______________

DONOR A PPLICATION
Thank you for applying to be a donor with Donor Egg Bank USA. We are appreciative of your willingness to participate in
our program to help women and men who are unable to conceive. It is very important that we learn as much as possible
about your personal and extended family medical history. This information is important to help us ensure you remain a
good candidate for egg donation as well as it gives our patients insight into your background to help them choose the best
donor for their family building purpose.
Please provide complete and accurate information to the following questions. If you have donated in the past, please
request a copy of your application so you may utilize it when filling out the family history portions. It will save you time and
help you remember accurately your family history without needing to consult family members again. As well, please
update any area of the application that may have changed since your last donation cycle. Any information you provide
during the donation process, will remain completely confidential. Some of the information from this questionnaire will be
given to the recipient(s), after all identifying information is removed. Prospective recipients will view your profile as well as
any baby, childhood or adult photos you provide.
Instructions:
1. Please fill in all blanks completely. Please complete all questions.
a. Incomplete applications will not be accepted or returned.
b. Please keep in mind that the information you provide will be viewed by potential recipients and do not
provide identifying information such as jobs, schools, names of relatives, etc.
c.

Please write legible and provide as much detail as possible. We will not correct grammatical mistakes
when uploading your profile to our database.

2. Please be specific. Avoid expressions such as natural or old age (for causes of death). List any health
problems as specifically as possible. If you do not know the age, put the approximate age or ask a relative to
help you. List exact relationships such as sister or brother, or maternal cousin, paternal grandfather (PGF).
a. A Yes response will not necessarily eliminate you as a potential donor. Most people will have at
least one or more of these conditions in themselves or a family member. The accuracy of the
information you will be providing will impact potential families you may help create.
3. Please provide information on all the relatives requested. Do not write their names.
a. If your grandparents were deceased prior to your birth, please ask a family member for their (your
grandparents) physical characteristics, cause of death and medical history. Do not write NA.
4. Please remember the donation is anonymous, therefore we ask that you do not list towns or potential
identifying information.
5. Please be sure to include at least 3 adult photographs of you alone and 3 childhood photographs, potential
recipients love to see pictures!
6. Before entering your height and weight, please weigh and measure yourself. It is important that this is
accurate and not an estimate.

Donor Name ________________

DONOR APPLICATION PROFILE

Date application was completed: ___________________

CONTACT INFORMATION
Name
Street Address
City, State, Zip Code
Home Phone

OK to leave Message?

Yes

No

Work Phone

OK to leave Message?

Yes

No

E-Mail Address
Last 4 digits of
Social Security Number
Place of Birth

Date of Birth
Partners Name

Phone

Emergency Contact Name

Phone

Fertility Center where

treatment will occur?

PHYSICAL CHARACTERISTICS
Please circle the race below that best describes you:
Caucasian

African American

Hispanic

Asian

Middle Eastern

Pacific Islander

Multi-Racial

What is your ancestors ethnic background or countries of origin? (French, German, Native American etc.):
__________________________________________________________________________________________
Are you of Jewish heritage or was your mother Jewish?
Age: ___________
Body Frame:

Small

Complexion:

Very Fair

Eye Color:

Blue

Height: _____________
Medium
Fair
Brown

Large
Light
Grey

Yes

Weight (lbs.): ______________

Dress Size: ____________ Shoe Size: ___________

Medium

Olive

Hazel

Green

Blood Type: _____________

No

Light Brown

Dark Brown

Ebony

Donor Name ________________

Hair (Check All That Apply):
Curly/wavy (Naturally)

Straight (Naturally)

Average Texture

Thin Texture

Thick Texture

Premature Graying (What Age: ______)

Natural Hair Color (Now): _________________
Are you:

Right Handed

Are you adopted?

Marital Status:

Yes
Single

Left Handed

Hair Color as a Child: _________________

Ambidextrous

No
Married

Divorced

Separated

Widowed

Partnered (same-sex only)

Religion: _________________________

EDUCATION
Select the highest level of education achieved:
GED
High School
Trade School (Type of Trade School: ___________________________________)
Some College
Associates Degree (Major: __________________________________________)
Bachelors Degree (Major: __________________________________________)
Some Graduate School (Major: __________________________________________)
Masters Degree (Major: __________________________________________)
Doctorate Degree (Major: __________________________________________)
Medical Degree
Law Degree

Do you have any additional educational goals? ___________________________________________________________

__________________________________________________________________________________________________
__________________________________________________________________________________________________

Donor Name ________________

PERSONAL WORK HISTORY
List jobs held in the past five years: *Please do not include name of employer/company - only job title*

Jobs/Duties

Year Began

Year End

SKILLS AND ABILITIES

What languages do you speak, read, or write? ____________________________________________________________

What were your academic strengths (i.e. Math, English, Science)? ____________________________________________

Athletic skills and/or favorite sports? ____________________________________________________________________

Have you done any volunteer work? If yes, please explain: __________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

Do you play any instruments? If yes, what do you play? ____________________________________________________

Donor Name ________________

Please rate your aptitudes on the following abilities (1 = Poor, 5 = Excellent):
Mathematical Ability:

Scientific Ability:

Athletic Ability:

Singing Ability:

Artistic Ability:

Additional Comments: ________________________________________________________________________________

__________________________________________________________________________________________________
__________________________________________________________________________________________________

PERSONAL MEDICAL AND SOCIAL HISTORY

Vision (Without Corrective Lenses):

Poor

Fair

Do you wear corrective lenses?

Yes

No

If yes, for what problem(s)?

Nearsighted

Have you had corrective eye surgery?

If yes, for what problem(s)?

Farsighted

Yes

Nearsighted

Poor

Do you wear hearing aids?

No

Condition of Teeth:

Yes

Poor

Have you ever had Dental Braces?

Excellent

Other (explain): ______________________________

No
Farsighted

Hearing (Without Corrective Aids):

Good

Fair

Other (explain): ______________________________

Good

Excellent

If yes, for what problem(s)? ________________________________

Fair

Good

Yes

No

Excellent

Do you smoke cigarettes?

Yes

No

If yes, how many cigarettes per day? _____________________

Do you drink alcohol?

Yes

No

If yes, how often? ____________________________________

Donor Name ________________

Diet:

Vegetarian

Diet (Nutrition):

Allergies:

Non-Vegetarian

Poor

Yes

If yes, are they to:

Average

Good

No
Food(s)

Medication(s)

Environmental

For each allergy, describe specific substance and reaction(s) and age first noticed:
Substance: __________________________

Reaction(s): _______________________________

Age: _______

Substance: __________________________

Reaction(s): _______________________________

Age: _______

Substance: __________________________

Reaction(s): _______________________________

Age: _______

Substance: __________________________

Reaction(s): _______________________________

Age: _______

Explain allergies you have outgrown: ___________________________________________________________________

_________________________________________________________________________________________________

Exercise:

None

Occasional

Regular

Type of Exercise: __________________________________________________________________________________

Have you had any surgery (ies):

Yes

No

If yes, please explain: ______________________________________________________________________________

Have you had any hospitalization(s) not mentioned above?

Yes

No

If yes, please explain: ______________________________________________________________________________

If yes, have you ever been hospitalized for psychiatric care?

Have you ever been convicted of a crime?

Yes

Yes

No

No

If yes, for what reason? _____________________________________________________________________________

Did you spend any time in jail?

Yes

No

If yes, for what length of time? __________________

Donor Name ________________

GYNECOLOGY AND FERTILITY HISTORY
Age menstrual periods began: ______________________________________

How many days does your period usually last? _________________________

Number of pregnancies: ____________________

Dates of pregnancies: ______________________________

Number of miscarriages: ___________________

Dates of miscarriages: _____________________________

Number of abortions: ______________________

Dates of abortions: ________________________________

Number of stillbirths: ______________________

Dates of each stillbirth: _____________________________

Number of children: _______________________

Are you Currently Breastfeeding? _____________________

Pregnancy #
Male / Female

Delivery Date

Complications

2.

3.

4.

5.

Length / Weight

Donor Name ________________

Child

Age
Sex
Eye Color
Hair Color
Frame Size
Age Walked
Age Talked
Age Toilet Trained
Grade Level in School
Wears Eye Glasses
Wears Braces
Hyperactive, ADD, ADHD
Discipline Problems
Any Medication
Attention Deficits
Emotional Problems
Dyslexia
Reading Difficulties
Speech Difficulties
Eye/Hand Motor Coordination
Any Special Services at School
Seen by Social Worker/Psychiatrist
Grade Function Average:
Normal / Above / Below

Donor Name ________________

GENETIC AND FAMILY HISTORY
Describe biological family members according to the following characteristics:
Use natural eye and hair color. Use fair, dark, olive etc. for complexion. Use small, medium, large for body frame.

Age
if
Living

Age at
Death

Cause of
Death

Eye
Color

Hair
Color

Mother

Father

Maternal
Grandmother

Maternal
Grandfather

Paternal
Grandmother

Paternal
Grandfather

Full Sibling
__M __F

Full Sibling
__M __F

Full Sibling
__M __F

Full Sibling
__M __F

Complexion

Height

Weight

Body
Frame

Ancestry

Donor Name ________________

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

No

If yes, please explain: _______________________________________________________________________________

_________________________________________________________________________________________________

Does anyone in your family, including yourself, experience baldness?

Yes

No

If yes, who? ________________________________________

What age(s) did they start balding? ________________

Are there any known genetic diseases or conditions that run in your family?
Yes

No

If yes, please identify: _______________________________________________________________________________

Have you or any family members described above had genetic counseling?
Yes

No

If yes, please describe: ______________________________________________________________________________

Are there any members of your family, including yourself and children, with a history of learning disabilities?
Yes

No

If yes, please explain: _______________________________________________________________________________

_________________________________________________________________________________________________

10

Donor Name ________________

Carefully review the following list of medical problems and identify any which are present in biological family members.
Please specify specific family members (e.g. Maternal Grandmother, Paternal Aunt etc.) and age of diagnosis if known.
*Please include only conditions diagnosed by a medical provider, not presumed diagnosis.*

You
Circulation
(check here if no to all

Child

Mother

Father

Brother

Stroke
Heart Attack
Congestive Heart Failure
High Blood Pressure
High Cholesterol
Congenital Heart Disease
Heart Disease
Blood
(check here if no to all

Anemia
Hemophilia or other
bleeding disorder
HIV/AIDS
Leukemia
Other Blood Disorder
Respiratory/Lungs
(check here if no to all

Asthma
Emphysema
Tuberculosis
Gastrointestinal
(check here if no to all

Ulcer of Stomach/Duodenum
Ulcerative Colitis
Hepatitis - A,B or C
Crohn's Disease
Inflammatory Bowel Disease
Any other cancer/problem
with digestive system

11

Sister

Grandparent

Aunt/
Uncle

st

1
Cousin

Comments

Donor Name ________________

You
Metabolic/Endocrine
(check here if no to all
Diabetes
(Requiring Insulin)
Diabetes
(Not Requiring Insulin)
Thyroid Disease
(Hypo/Hyper)

Child

Mother

Father

Brother

Adrenal Gland Disorder

PKU or Inherited
Metabolism Disorder
Dwarfism
Urinary
(check here if no to all

Kidney Disease
Other disease/defect
of urinary tract
(urethra, bladder, ureter)
Genital/Reproductive
(check here if no to all

Infertility
Miscarriage or Stillborn
Uterine Fibroids
Endometriosis
Ovarian Cysts
Other Genital
or Reproductive Diseases
Nervous System
(check here if no to all

Migraine Headaches
Mental retardation
Senility before age 50
Multiple Sclerosis
Cerebral Palsy
Epilepsy/Seizure
Spina Bifida
(Neural Tube Defect)
Parkinson's Disease
Alzheimers Disease
Huntington's Disease
Brain Tumor

12

Sister

Grandparent

Aunt/
Uncle

st

1
Cousin

Comments

Donor Name ________________

You
Mental Health
or Learning Disability
(check here if no to all

Child

Mother

Father

Brother

Depression (Current or Past)

Schizophrenia
Manic Depressive
or Bipolar Disorder
Alcoholism
Drug or Substance Abuse
Learning Disabilities
Other issues requiring
hospitalization/treatment with
psychotropic medication
Muscles/Bones/Joints
(check here if no to all

Muscular Dystrophy
Other chronic
muscle disease
Auto Immune Diseases
(i.e. Lupus)
Marfan Syndrome
Arthritis
Gout
Sight/Sound/Smell
(check here if no to all

Deafness Before Age 60

Deformity of the Ear
Cataracts Before Age 60
Blindness
Glaucoma
Retinoblastoma
Any other sight/sound/smell
impairments
Vision
Please note if any family
member wears glasses,
contacts or had corrective
eye surgery (LASIX).

13

Sister

Grandparent

Aunt/
Uncle

st

1
Cousin

Comments

Donor Name ________________

You
Skin
(check here if no to all

Child

Mother

Father

Bother

Albinism
Pigmentation Disorders
Neurofibromatosis
Other Skin Disorders
Cancer
(check here if no to all

Breast
Ovarian
Colon
Skin
Thyroid
Cervical
Uterine
Lung Cancer
Prostate or Testicular
Genetic Disease Disorders
(check here if no to all )
Cystic Fibrosis
Sickle Cell Anemia
Tay Sachs
Canavan
Gaucher
Other:
Other Medical Conditions
(check here if no to all )
Birth Defects
Early Death
(Under Age 51)
Genetic Disorder
Club Feet
Cleft lip or Palate
Any other Cancer
Any other Condition

14

Sister

Grandparent

Aunt/
Uncle

st

1
Cousin

Comments

Donor Name ________________

PERSONAL AND MOTIVATION
Explain the reason for wanting to donate your eggs:
_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

Describe your personality, character and temperament:

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

What physical, artistic, intellectual or social abilities do you feel best about?
_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

15

Donor Name ________________

What are your hobbies, interests, and talents?
_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

What are your future plans and goals?

_________________________________________________________________________________________________

_________________________________________________________________________________________________

What are you sorry you did not do?

_________________________________________________________________________________________________

_________________________________________________________________________________________________

What other information would you like a Recipient to know about you?
_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

16

Donor Name ________________

PLEASE ATTACH A MINIMUM OF SIX COLOR PHOTOGRAPHS OF YOURSELF ON THIS PAGE; THREE
AS A CHILD (AGE 10 AND UNDER) AND THREE PHOTOS OF YOU AS AN ADULT. PLEASE ENSURE
ALL PHOTOGRAPHS ARE CLEAR AND COMPLIMENTARY TO YOU. PLEASE ENSURE THE PHOTOS
ARE DISCREET AND MODEST.
(*APPLICATIONS WITHOUT PHOTOS WILL NOT BE ACCEPTED)

The undersigned agrees that, to the best of her knowledge and belief, the information
provided in this application is complete and correct. The undersigned acknowledges that
her profile, childhood and adult photographs may be placed on Donor Egg Bank USAs
website for patients viewing. The undersigned furthermore agrees to report to Donor Egg
Bank USA and the Fertility Center in which she cycles, any significant changes in the
status of her health, especially in regards to sexually transmitted disease.

NAME OF EGG DONOR (PRINTED):

EGG DONOR (SIGNATURE):

DATE:

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