Donor Egg Program Questionnaire

All Fields Required.
What is your name?
What is your address?
Address:
Suite:
Apt:
Box:
City:
Province / State:
Postal / Zip Code:
What is your date of birth? mm/dd/yyyy  Age:
What is the primary phone number you want us to use to communicate with you? xxx-xxx-xxxx
What is the best email address for us to reach you at?
Are you within 2 hours of the Center for Reproductive Medicine in Minneapolis?
What is your accurate height (in feet/inches) and weight (in pounds)Height:  Feet  Inches  Weight: Pounds 
BMI:
Please enter height and weight to calculate BMI.
What is your ethnic background?
 Other: 
What is your highest level of education?
 Other: 
Have you donated your eggs before? If yes, CRM would like to receive the records.
Do you smoke? If yes, on a social basis, you will be required to abstain during treatment.
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.
Have you used any illicit drugs during the last six months?
Are you currently taking medication? If yes, please list (including over the counter vitamins/herbs, not including birth control):
List medications and reasons for taking if applicable:
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?
 Other: 
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?
 Other: 
Have you ever been pregnant?
Have you had any miscarriages? If yes, how many?
If 1 or more, do you know the reason why?
Do you have both ovaries?
Have you ever had a laparoscopy that showed endometriosis?
How did you first learn about the opportunity to donate your eggs at CRM?
 Other: 
Using the checkboxes below, please list any relevant medical history.
Chemical dependency  None  Self  Father  Mother  Sibling  Grandparents  Aunts  Uncles  Cousins 
Drug addiction  None  Self  Father  Mother  Sibling  Grandparents  Aunts  Uncles  Cousins 
Alcoholism  None  Self  Father  Mother  Sibling  Grandparents  Aunts  Uncles  Cousins 
Diagnosis of depression  None  Self  Father  Mother  Sibling  Grandparents  Aunts  Uncles  Cousins 
Mental Illness  None  Self  Father  Mother  Sibling  Grandparents  Aunts  Uncles  Cousins 
ADHD or ADD  None  Self  Father  Mother  Sibling  Grandparents  Aunts  Uncles  Cousins 
Chromosomal abnormalities  None  Self  Father  Mother  Sibling  Grandparents  Aunts  Uncles  Cousins 
Birth defects  None  Self  Father  Mother  Sibling  Grandparents  Aunts  Uncles  Cousins 
Is there anything else of concern medically or in more distantly related relatives?
List applicable medical problems / history:
Will you be able to give detailed medical information from both sides of your family going back to your grandparents? This includes diseases, causes of death, age at death. This may require interview family members for accurate information.
Are you willing to undergo a psychological consult and personality testing?
Are you willing to take injectable medications? (training provided)
What type of health insurance do you have?
 Other: 
Marital Status
 Other: 
For more information visit www.ivfmn.com. Donors at CRM can donate up to 6 times and are compensated $5,000.00 each time they donate. Also, please be aware that the clinic must also submit a 1099 income statement.
Please note: We use a secure server for online convenience and privacy. An Egg Donor Program Coordinator will be in touch with you shortly.