Growing Generations - An Example Egg Donor Profile

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Introduction

Personal Bio

Education Information

Health / Reproductive History

Family / Genetic History

First Name:

Jennifer

Donor #

101

Do you smoke or use tobacco in any form?

Do you drink alcoholic beverages?

Have you had any Tattoos or body piercing?

Have you ever had plastic surgery or reconstructive surgery?

Have you ever taken recreational drugs?

Do you feel you were ever a victim of sexual, physical or psychological abuse?

List any medications you are currently taking:

NONE

List any past or current medical conditions:

NONE

List all surgeries, dates performed and for what reason:

Bone Marrow transfer in 1998 to my sister.

Do you have any of the following health conditions now or in the past?
Please explain any "yes" answers.

TB or exposed to TB	No
Cancer	No
Asthma	No
Irregular Heartbeat	No
Heart Problem	No
Head Injury	No
High Blood Pressure	No
Migraine Headaches	No
Thyroid Problem	No
Seizures/Fits	No
Diabetes	No
Anemia	No
Hemorrhoids	No
Genital Warts/Sores	No
Ovarian Cysts	No
PID	No
Uterine Fibroids	No

Have you or your partner/spouse been diagnosed with any of the following?
Please explain any "yes" answers.

Herpes	No
Gonorrhea	No
Syphillis	No
HIV	No
Hepatitis B	No
Hepatitis C	No

How many times have you been pregnant?

N/A

How many children do you have?

N/A

Please fill out the following form with details for each pregnancy:

Pregnancy History	Pregnancy #1	Pregnancy #2	Pregnancy #3	Pregnancy #4
Months Trying to Conceive	N/A	N/A	N/A	N/A
Date of Delivery	N/A	N/A	N/A	N/A
Birth Weight	N/A	N/A	N/A	N/A
Premature Birth How Early?	N/A	N/A	N/A	N/A
Stillbirth Explain	N/A	N/A	N/A	N/A
Abortions List Any Complications	N/A	N/A	N/A	N/A
Miscarriages If yes, How far along?	N/A	N/A	N/A	N/A

Describe you children's current health and any history of problems:

N/A

Have you ever had an abortion because of abnormal fetal development?

Have you ever undergone any fertility treatments to become pregnant?

List any obstetrical complications you have had (premature delivery, bedrest, gestational diabetes)

N/A

Describe your current relationship status:

Consistent partner

What is your sexual orientation?

Heterosexual

If applicable, list method of current birth control below:

Type of contraception currently using:	Condoms, Birth Control Pills
How long have you been using this form of birth control?	4 yrs.
Do you use condoms along with birth control?	No
Do you have a menstrual cycle every month?	Yes

Do you have the following ancestry?

No	Jewish
No	Black
No	French Canadian
No	Italian/Greek
No	South East Asian

Have you been tested as a carrier of Thalessemia?

Have you been tested as a carrier of Tay Sachs?

Have you been tested as a carrier of Sickle Cell?

Have you been tested as a carrier for Cystic Fibrosis?