Donor Application Full | International Egg Bank

Complete the full application

At this time, we are seeking potential egg donors among healthy women from all walks of life. You must possess some form of higher education, above the high school level. Potential donors must be willing to complete a thorough screening process. International Egg Bank’s screening process evaluates general and reproductive health, genetic history and psychological stability. To be considered for Egg Donation, you must be:

Between ages 19-34
Non-smoker
No alcohol and/or drug abuse or addiction
Have knowledge of medical and genetic history of family members up to biological grandparents (even if applicant is adopted, they must know this information)
Healthy Body Mass Index
Be willing to administer medications by injection (the needles are tiny and hardly felt)
Willing to provide current and childhood photos

Please do not leave any question blank.

Egg Donor Application

Date:

Full Legal Name:

Present Address:

Home Phone:

May we leave a message?

Yes

Work Phone:

May we leave a message?

Yes

Cell Phone:

May we leave a message?

Yes

Email Address:

Social Security #

Who to contact in case of Emergency:

Phone:

Relationship:

How did you hear about us?

Would you be interested in donating to a single parent?

Yes

To a same sex couple?

Yes

The following information will be shown to potential recipients for their review. Do not put any identifying information on the following pages. If a couple chooses you as their donor, they will keep this information as a medical history base for their potential offspring. We appreciate your accuracy in filling out your donor application. Please include as much detail as possible when filling in your family medical history.

Date of Birth:

Between the age of 18 & 35?

Yes

Height:

Weight:

Eye Color:

Natural Hair Color:

Skin Tone:

Fair

Medium

Olive

Dark

Are you

Right Handed

Left Handed

Ambidextrous

Ancestral Background of Mother:

Ancestral Background of Father:

Are you adopted?

If yes, do you know the medical history of your birth parents?

Are either of your biological parents adopted?

Religion:

Currently practicing?

Yes

Have you ever been an egg donor before?

Yes

If yes, who was the doctor?

Do you know if your donation resulted in a pregnancy?

Are you currently employed?

Yes

If yes, what is your occupation?

Future career goals?

Have you ever been arrested?

Yes

If yes, please explain when and why:

Completed High School?

Yes

Year

GPA

Received GED

Yes

Year

Testing Scores: SAT

ACT

GRE

MCAT

Other

Do you have any college education or attended any certification programs?

Yes

If yes, what college or certification program do/did you attend?

What is/was your major?

Did you earn a degree?

Yes

GPA

If yes, what is it?

If no, when will you finish your degree?

Have you pursued an advanced degree?

Yes

If yes, name of the institution:

What is the degree in?

Honors and Awards:

List your favorite classes:

List your least favorite classes:

Education level of Mother:

Mother's Occupation:

Education level of Father:

Father's Occupation:

Education level of Siblings:

Sibling's Occupations:

Describe your current health status:

Excellent

Good

Fair

Poor

Date of your last physical exam:

Are you currently under a physician's care for any reason?

Yes

If yes, please explain:

Do you exercise regularly?

Yes

Vision (check the appropriate):

20/20

Near sighted

Far sighted

If near or far sighted, please check the severity:

Mild

Moderate

Severe

Do you have (check the appropriate):

Glasses

Contacts

Corrective Eye Surgery

None

Hearing:

Normal

Impaired

If impaired, please explain:

Blood Type (if known):

Have you ever had a blood transfusion:

Yes

If yes, please explain when & why:

Have you ever had any surgery (including plastic surgery)?

Yes

If yes, please explain the surgical procedure and date:

Have you ever worn braces?

Yes

Please list any major illnesses you have experienced:

Do you have any allergies to food, medications and other substances?

Yes

If yes, please explain:

List any prescription, non-prescription medications, vitamins or herbs that you are taking: Name of Drug How Often? Reason Length of Time

Have you ever taken any anti-depressants, tranquilizers or anti-anxiety medication?

Yes

If yes, please explain:

Do you or have you ever used any recreational/illegal drugs (including steroids)?

Yes

If yes, please list and explain:

Have you ever smoked?

Yes

If yes, when did you quit?

Do you drink alcoholic beverages?

Yes

How old were you when you started drinking?

Have you had any body piercing, tattooing or acupuncture in the last 12 months?

Yes

If yes, please describe:

Have you injected drugs for a non-medical reason in the preceding five years, including intravenous, intramuscular, or subcutaneous injections?

Yes

If yes, please describe:

Do you have hemophilia? If yes, do you use human-derived clotting factor?

Yes

If yes, please describe:

Have you engaged in sex in exchange for money or drugs in the preceding five years?

Yes

If yes, please describe:

Have you had sex or have you been exposed in the preceding 12 months with any person known or suspected to have HIV infection, clinically active hepatitis infection, or hepatitis C infection or been in contact with an open wound, non-intact skin, or mucous membrane?

Yes

If yes, please describe:

Have you had close contact within 12 months preceding donation with another person having clinically active viral hepatitis (e.g. living in the same household, where sharing of kitchen and bathroom facilities occurs regularly?

Yes

If yes, please describe:

Have you been diagnosed with viral hepatitis after age 11? Unless evidence from the time of illness documents that the hepatitis was identified as hepatitis (e.g. a reactive IgM anti-HAV test)?

Yes

If yes, please describe:

Have you had a recent smallpox vaccination (Vaccinia virus) in the last 60 days? If less than 60 days, did the scab separate by some other means than spontaneously?

Yes

If yes, please describe:

Do you have a clinically recognizable vaccinia virus infection contracted by close contact with someone who received the smallpox vaccine? (The Physical assessment should also check for this)

Yes

If yes, please describe:

Have you had a medical diagnosis of WNV infection?

Yes

If yes, please describe:

Have you had both a fever and a headache (simultaneously) during the 7 days prior to donation?

Yes

If yes, please describe:

Have you had close contact with a xenotransplantation product recipient? Have you, your sexual partner or any member of his/her household ever had a transplant?

Yes

If yes, please describe:

Have you had a transfusion or received blood or blood products in the last 48 hours?

Yes

If yes, please describe:

Have you been diagnosed with or treated for Chlamydia?

Yes

If yes, please describe:

Have you been diagnosed with or treated for Gonorrhea?

Yes

If yes, please describe:

Have you ever been diagnosed with vCJD or any other form of CJD?

Yes

If yes, please describe:

Have you ever had a diagnosis of dementia or any other degenerative or demyelinating disease of the central nervous system (CNS) or other neurological disease of unknown etiology?

Yes

If yes, please describe:

Have you ever had a blood relative diagnosed with CJD?

Yes

If yes, please describe:

Have you ever taken human pituitary-derived growth hormone?

Yes

If yes, please describe:

Have you ever received a dura mater transplant?

Yes

If yes, please describe:

Have you spent three months or more cumulatively in the UK (United Kingdom) from the beginning of 1980 through the end of 1996?

Yes

If yes, please describe:

Are you a current or former U.S. military member, civilian military employee or dependent of a military member or civilian employee who resided at U.S. military bases in Northern Europe (Germany, UK, Belgium and the Netherlands) for 6 months or more from 1980 through 1990, or elsewhere in Europe (Greece, Turkey, Spain, Portugal, and Italy) for 6 months or more from 1980 through 1996?

Yes

If yes, please describe:

Have you lived cumulatively for 5 years or more in Europe from 1980 until the present (note this criterion included time spent in the UK from 1980 through 1996)?

Yes

If yes, please describe:

Have you received any transfusion of blood or blood components in the UK between 1980 and the present?

Yes

If yes, please describe:

Have you injected bovine insulin since 1980, unless you can confirm that the product was not manufactured after 1980 from cattle in the UK?

Yes

If yes, please describe:

Are you currently sexually active?

Yes

If yes, are you in a monogamous relationship (only one sexual partner at a time)?

Yes

What type of contraception are you currently using? (check the appropriate)

How long have you been using this form of birth control?

Have you or any of your sexual partners ever had sex with gay/bisexual men or IV drug users?

Yes

Do you have any clinical or laboratory evidence of HIV (AIDS) or hepatitis infection?

Yes

Have you had sex with any person with known or suspected HIV (AIDS) or hepatitis infection?

Yes

Have you been exposed to known to potentially HIV or hepatitis-infected blood through needle sticks, an open wound, or mucous membranes in the last 12 months?

Yes

Do you have regular periods?

Yes

Age at onset of first menstrual period:

How many days apart are your periods?

Duration of flow:

Do you have any problems related to your periods?

Yes

If yes, please explain:

Date of last pap smear:

Was the pap smear

Normal

Abnormal

Have you ever had an abnormal pap smear?

Yes

If abnormal, please explain:

Have you ever been pregnant?

Yes

If yes, how many children do you have?

Age and sex of child/children:

Describe your child/children's current health history and any medical problems:

Are you currently breastfeeding?

Yes

Have you ever had an abortion?

Yes

If yes, how many times?

Have you ever had a miscarriage?

Yes

If yes, how many times and what were the circumstances? (how far along were you, health problems, etc.)

Do you have any family history of miscarriage?

Yes

Have you ever undergone any fertility treatments to become pregnant?

Yes

If yes, please explain:

Explain your personal reasons for becoming an egg donor:

Have you discussed your desire to donate with your family/friends? Are they supportive of your decision?

Describe your personality (both positive and negative aspects):

What skills or talents do you possess (i.e. arts, academics, interactive skills, etc.)? Have you received any types of rewards or recognition for these skills/talents?

What are your hobbies and interests?

What clubs, organizations, groups or teams do you belong to or have belonged to in the past?

What physical activities do you participate in? What physical activities do you excel in? Have you received any awards or recognition in regard to these activities?

Do you have any vocal ability or do you play any instruments?

Do you speak, write or read any languages besides English?

What accomplishments are you particularly proud of (i.e. completed goals, careers)?

How would you describe your childhood?

Mother: Age, Natural Hair Color, Eye Color, Height, Weight, Still Living? Deceased? Date/Cause of Death

Father: Age, Natural Hair Color, Eye Color, Height, Weight, Still Living? Deceased? Date/Cause of Death

Maternal Grandmother: Age, Natural Hair Color, Eye Color, Height, Weight, Still Living? Deceased? Date/Cause of Death

Maternal Grandfather: Age, Natural Hair Color, Eye Color, Height, Weight, Still Living? Deceased? Date/Cause of Death

Paternal Grandmother: Age, Natural Hair Color, Eye Color, Height, Weight, Still Living? Deceased? Date/Cause of Death

Paternal Grandfather: Age, Natural Hair Color, Eye Color, Height, Weight, Still Living? Deceased? Date/Cause of Death

Brother(s): Age, Natural Hair Color, Eye Color, Height, Weight, Still Living? Deceased? Date/Cause of Death

Sister(s): Age, Natural Hair Color, Eye Color, Height, Weight, Still Living? Deceased? Date/Cause of Death