Donor Egg Program Questionnaire

Personal Information

What is your name?*

What is your date of birth?*

Age:*

What is your accurate height (in feet/inches)*

What is your accurate weight (in pounds)*

BMI:

Please enter height and weight to calculate.

How did you first learn about the opportunity to donate your eggs at CRM?*

Have you donated your eggs before? If yes, CRM would like to receive the records.*

What is your address?*

What is the primary phone number you want us to use to communicate with you?*

What is the best email address for us to reach you?*

Are you within 2 hours of the Center for Reproductive Medicine in Minneapolis?*

Background Information

What is your ethnic background?*

What is your highest level of education?*

Social History

Do you smoke? If yes, on a social basis, you will be required to abstain during treatment.*

Have you used any illicit drugs during the last six months?*

Do you drink? If yes, approximately how many drinks do you have in a week? Donor will be asked to abstain from drinking alcoholic beverages during treatment.*

Medication Information

Are you currently taking medication? *

Are you willing to have numerous screening blood tests, including HIV, STD and urine drug screening testing?*

What kind of birth control method are you currently using?*

Menstrual Information

Have you ever been pregnant?*

Have you had any miscarriages?*

Do you have both ovaries?*

Have you ever had a laparoscopy that showed endometriosis?*

What is the usual range of your menstrual cycle from day 1 of your period to day 1 of your next period when you are not on birth control?*

Medical History