infertility second opinioninfertility second opinioninfertility second opinion

What to expect  infertility second opinion  
FAQs  infertility second opinion  
Policy and Procedures  infertility second opinion  
Apply Online  infertility second opinion  
 infertility second opinion
Please take time to accurately complete the online application form in order to assure your success in becoming a qualified donor! Also be reminded that you must live relatively close to our center to donate
First Name:  *
Last Name:  *
Date of Birth:

  * (mm/dd/yyyy)
Address 1:
Address 2:
City:
State:
Zip:
Home Phone:
Daytime Phone: *
email: *
Alternate Phone:
I heard about egg donation through:
 A friend or another donor Name: 
 A patient of CHR Name: 
 Advertisement Where: 
online
If accepted as an egg donor I would be available to serve beginning:
 Immediately
 Starting as of  (mm/dd/yyyy)
I would be most interested in donating eggs at:
Marital Status:
 Single with one partner
 Single and dating
 Separated or Divorced
 Engaged
 Married
 Living together
Place of Birth:
City:
State/Province:
Country:
Ethnicity (check all that apply):
Aborigine African
Asian South Asian
Caucasian Hispanic
Indonesian Mediterranean
Native American West Indian
Other Enter Other: 
Please select your ancestry and provide the
percentage. You can add up to 8 ancestries.
 %  
 %  
 %  
 %  
 %  
 %  
 %  
 %  
Religion Born into:
 Buddhist
 Christian
 Hindu
 Jewish
 Islamic
 Other Enter Other: 

Personal Characteristics

Height:
Weight:
Enter Weight:  lbs
Build:
Eye Color:
Natural Hair Color:
Type of Hair (check all that apply):
Straight Wavy
Thick Fine
Curly Coarse
Frizzy Kinky
Do you wear corrective lenses:
 Yes
 No
Are you predominantly:
 Right Handed
 Left Handed
Skin Tone:
Freckles:
Additional Characteristics (check all that apply):
Cleft Chin
Big Eyes
High Cheek Bones
Full Lips
Other Enter Other: 

Education/Work/Interests

Educational Background (check all that apply):
Some High School
High School Graduate
G.E.D.
Tech/Trade School
Some College
Bachelor's Degree
 Degree Achieved:
 Major Area of Study:
Associate's Degree
 Degree Achieved:
 Major Area of Study:
Graduate Study
Graduate Degree
Degree Achieved:
Masters
MBA
Ph.D.
D.O.
M.D.
Law
Major Area of Study: 
Post Graduate Study
 Other Enter Other: 
S.A.T. Scores:
Total Score:
Verbal:
Math:
Other Placement Scores:
LSAT:
MCAT:
GRE:
Other:
Work/Occupation History
I currently work in the home
I am currently a full time student
I am currently unemployed
I currently work part time
I currently work full time
Enter Occupation: 
What kind of work have you done in the past?
What kind of work is most appealing to you?

Personal Preferences/Abilities:

Are you skilled mechanically or technically?
 Yes
 No
How would you rate your Abilities in Mathematics:
 Poor
 Average
 Excellent
Literary Skills:
 Poor
 Average
 Excellent
Scientific/Research Ability:
 Poor
 Average
 Excellent
Athletic Abilities
 Poor
 Average
 Excellent
Do you have a favorite sport?
 Yes
 No
Please list your favorite sports:
How would you rate your Musical Skills/Ability:
 Poor
 Average
 Excellent
Artistic Talents:
 Poor
 Average
 Excellent
Other than English, what languages do you speak?
(check all that apply):
Chinese Czech
Farsi French
German Greek
Hebrew Hungarian
Italian Japanese
Polish Portuguese
Russian Spanish
Ukrainian  
Other Enter Other: 
Do you have any special talents or hobbies?
 Yes
 No
If yes, please list your talents or hobbies:
How would you describe your personality?
What is your ultimate ambition in life?

Social History

Tobacco (Check all that currently apply):
I currently smoke
I am a heavy smoker
I used to smoke but no longer do
I have never smoked cigarettes
Alcohol
 I never drink alcohol
 I drink  times per week
 I rarely drink alcohol (less than twice a year)
Drug usage:
 I have never used illegal drugs
 I have tried illegal drugs at least once in the past
 I used to do drugs regularly but don't anymore
 I am currently using one or more of the following:
 Enter usages: 
Have you ever used injectable drugs?
 Yes
 No
 Unanswered
If yes, when did you last use injectable drugs?
Sexual Behavior:
Have you ever worked as a prostitute in the past?
Yes
No
 Unanswered
Have you ever engaged in homosexual activities
Yes
No
Have you ever engaged in heterosexual activity with a prostitute within the previous six months?
Yes
No
 Unanswered
Have you ever engaged in sexual activities with more than one partner on regular basis
Yes
No
Do you consider yourself to be bisexual
Yes
No
Do you consider yourself to be homosexual
Yes
No
Do you consider yourself to be heterosexual
Yes
No
The Law (check all that apply):
 I have never had any legal trouble
 I have had legal trouble in the past
If yes, explain the type of legal trouble you have had:
Crimes:
I have been convicted of a crime
I have spent time in prison
What was the crime you were convicted of perpetrating?

Psychological History:

Have you ever sought counseling for depression or emotional problems?
 Yes
 No
Have you ever taken antidepressants for more than three months at a time?
 Yes
 No
 Unanswered
Have you ever been diagnosed with depression?
 Yes
 No
 Unanswered
Have you ever been diagnosed with schizophrenia?
 Yes
 No
 Unanswered
Have you ever been diagnosed with manic depression?
 Yes
 No
 Unanswered
Have you ever been diagnosed with obsessive-compulsive disorder?
 Yes
 No
 Unanswered
Have you ever been diagnosed with mania?
 Yes
 No
 Unanswered
Have you ever been diagnosed with anorexia or bulimia?
 Yes
 No
 Unanswered
Have you ever been diagnosed with self mutilation?
 Yes
 No
 Unanswered

Personal Health History:

Do you have any allergies that you're aware of?
 Yes
 No
If yes, please indicate what you are allergic to:
Are you allergic to any medications?
 Yes
 No
If yes, please tell us what medication you're allergic to:
Were you or any of your relatives born with genetic disorders that led to hearing impairment?
 Yes
 No
 Unanswered
Do you have any dietary restrictions?
 Yes
 No
If yes, what are your dietary restrictions, and for what reason?
Do you take any supplemental vitamins or herbal remedies on a continual basis?
 Yes
 No
If yes, please list what vitamins or herbal remedies you are taking:
Do you take any prescription or over the counter medication on a regular or continual basis?
 Yes
 No
If yes, please list what medication you are currently taking:
Do you exercise regularly?
 Yes
 No
Have you had any surgeries in the past?
 Yes
 No
If yes, please indicate what surgeries you have had:
Have you ever had an adverse reaction to general anesthetics?
 Yes
 No
 Unanswered
If yes, please indicate what happened, and the severity of the response:
Have you ever been hospitalized for anything other than the above listed surgeries?
 Yes
 No
If yes, please tell us why you were hospitalized:

Menstrual History:

(please answer the following questions about your menstrual cycle)
How old were you when you first began to menstruate:
 10
 11
 12
 13
 14
 15
Other Enter Other: 
How many days are there (usually) between one period to the next?
 26-28
 29-32
 Other Enter Other: 
How many days do your periods usually last?
 2-3
 4-5
 6-8
 Other Enter Other: 
Do you ever experience mid-cycle bleeding?
 Yes
 No
Would you describe your menstrual cycle as:
 Regular
 Irregular
In general, how heavy is your menstrual flow?
 Light
 Moderate
 Heavy
 Very Heavy
Have you ever taken, or are you currently taking oral contraceptives?
 Yes
 No
If yes, what brand and for how long?
What methods of contraceptive have you used? Please list:

Sexual Activity/History:

(please answer the following questions about your sexual history)
How many sexual partners have you had intercourse with in the past year?
 1
 2
 3
 4 or more
Have you been with a sexual partner that is a known user of drugs?
 Yes
 No
 Unanswered
Have you had intercourse with a bisexual or homosexual partner?
 Yes
 No
 Unanswered
Have you had intercourse without the use of a condom in the last year?
 Yes
 No
 Unanswered
Have any of your past or present sexual partners shown evidence of having HIV infection?
 Yes
 No
 Unanswered
Have you ever been with a sexual partner who tested positive for a sexually transmitted disease?
 Yes
 No
 Unanswered
If you answered yes to any of the above questions, please explain in full detail:

Pregnancy History:

Have you ever been pregnant?
 Yes
 No
If yes, how many times have you been pregnant?
Have you ever carried a pregnancy to term?
 Yes
 No
If yes, were there any complications with gestation or delivery?
 Yes
 No
If yes, what were the complications?
How many times have you given birth?
 1
 2
 3
 4
 more
Has every delivery resulted in a live birth?
 Yes
 No
Have you ever been told in the past, that you have sexually transmitted disease?
 Yes
 No
 Unanswered
Have you ever been told in the past, that you have Chlamydia?
 Yes
 No
 Unanswered
Have you ever been told in the past, that you have HIV or AIDS or HTLV?
 Yes
 No
 Unanswered
Have you ever been told in the past, that you have condyloma?
 Yes
 No
 Unanswered
Have you ever been told in the past, that you have Ureaplasma/Mycoplasma?
 Yes
 No
 Unanswered
Have you ever been told in the past, that you have Autoimmune Disorder?
 Yes
 No
 Unanswered
Have you ever been told in the past, that you have Syphilis or Gonorrhea?
 Yes
 No
 Unanswered
Have you ever been told in the past, that you have Ovarian Cysts?
 Yes
 No
 Unanswered
Have you ever been told in the past, that you have Multiple Sclerosis?
 Yes
 No
 Unanswered
Have you ever been told in the past, that you have Alzheimer's Disease?
 Yes
 No
 Unanswered
Have you ever been told in the past, that you have Tuberculosis?
 Yes
 No
 Unanswered
Have you ever been told in the past, that you have Herpes Simplex Virus I or II?
 Yes
 No
 Unanswered
Have you ever been told in the past, that you have Abnormal Pap Smear?
 Yes
 No
 Unanswered
Have you ever been told in the past, that you have Cancer?
 Yes
 No
 Unanswered
Have you ever been told in the past, that you have Hepatitis A, B or C?
 Yes
 No
 Unanswered
Have you ever been told in the past, that you have Endometriosis?
 Yes
 No
 Unanswered
Have you ever been told in the past, that you have Fibroids?
 Yes
 No
 Unanswered
Have you ever been told in the past, that you have Pelvic Inflammatory Disease?
 Yes
 No
 Unanswered
Have you ever been told in the past, that you have Hypertension?
 Yes
 No
 Unanswered
Have you ever been told in the past, that you have Endocrine Disease?
 Yes
 No
 Unanswered
Have you ever been told in the past, that you have Sepsis?
 Yes
 No
 Unanswered
Have you ever been told in the past, that you or relative have West Nile Virus?
 Yes
 No
 Unanswered
Have you ever been told in the past, that you have Vaccinia?
 Yes
 No
 Unanswered
Have you ever been told in the past, that you have Creutzfeld-Jakob disease (CJD)?
 Yes
 No
 Unanswered
Have you ever been told in the past, that you have Chagas Disease, protozoan parasite infection, T. Cruzi?
 Yes
 No
 Unanswered
Do you have an occupation with risk of exposure to radiation or other chemicals that could be harmful to your health?
 Yes
 No
 Unanswered
If yes, please explain what chemicals you are or have been exposed to:
Have you had a Pap Smear within the past 6 months?
 Yes
 No
Was result of your Pap Smear within normal limits?
 Yes
 No
 
Have you received a blood transfusion within the past six months?
 Yes
 No
 Unanswered
Have you ever received a blood transfusion or other blood products at any time in your life?
 Yes
 No
 Unanswered
If yes, when did this happen?
Are you a current or former U.S. military or civilian military employee (or dependent), who resided on a
military base in Germany, Belgium, or The Netherlands for 6 months or more between 1980-1990?

Are you a current or former U.S. military or civilian military employee (or dependent), who resided on a
military base in Greece, Turkey, Spain, Portugal, or Italy for 6 months or more between 1980-1996?

Have you ever spent 5 or more cumulative years in Europe?
Did you spend 3 or more cumulative months in the U.K. between 1980-1996?

Have you received any blood transfusions or transfusions of blood products in the U.K. or France?

Have you or your sexual partner lived in Cameroon, Central African Republic, Chad, Congo,
Equatorial Guinea, Gabon, Niger, or  Nigeria since 1977?

Have you ever received blood transfusions or other blood products in any of the African countries listed above?
Ever been diagnosed with dementia, or other diseases of the central nervous system?
Ever received a human pituitary-derived growth hormone?
Ever had a non-synthetic dura mater transplant?
 
 
Ever received any transplantation of living cells (xenotransplant), or had intimate
contact with any xenotransplant recipient?
 
 
Have you acquired a tattoo within the last year?
 Yes
 No
 Unanswered
If yes, when did you get your newest tattoo?
Have you ever had an animal bite or rabies?
 Yes
 No
 Unanswered
Have you ever received blood products or clotting factors for abnormal bleeding?
 Yes
 No
Have you ever been excluded from blood donation?
 Yes
 No
If yes, please explain when and why:
Have you ever received Pituitary derived growth hormone?
 Yes
 No
 Unanswered

Family History

 
RelativeAlive?Present age or age of deathHeightWeightHair ColorEye ColorAny Medical ProblemsOccupationBirth Place
Mother  Yes
 No
Maternal Grandmother  Yes
 No
Maternal Grandfather  Yes 
 No
Father  Yes 
 No
Paternal Grandmother  Yes 
 No
Paternal Grandfather  Yes 
 No
Sibling 1  Yes 
 No
Sibling 2  Yes 
 No
Your Own Child 1  Yes 
 No
Your Own Child 2  Yes 
 No
Please tell us if any member of your family has any of the conditions listed below. Check all that apply and indicate who in your family has the condition.
ConditionSelfFamilyWho in the Family?
Cleft PalateNoYesNo
Spina BifidaNoYesNo
Thyroid DiseaseNoYesNo
ClubfootNoYesNo
Mental RetardationNoYesNo
Down's SyndromeNoYesNo
Cystic FibrosisNoYesNo
Marfan SyndromeNoYesNo
AlbinismNoYesNo
Muscular DystrophyNoYesNo
Cancer (indicate type)NoYesNo
SchizophreniaNoYesNo
Clinical DepressionNoYesNo
Obsessive-Compulsive DisorderNoYesNo
ManiaNoYesNo
Tay Sachs DiseaseNoYesNo
Canavan's DiseaseNoYesNo
Hemolytic AnemiaNoYesNo
BlindnessNoYesNo
Hearing ImpairmentNoYesNo
Color BlindnessNoYesNo
Heart DiseaseNoYesNo
Parkison's DiseaseNoYesNo
HemochromatosisNoYesNo
High CholesterolNoYesNo
Sickle Cell AnemiaNoYesNo
HemophiliaNoYesNo
Huntington's DiseaseNoYesNo
DiabetesNoYesNo
Multiple SclerosisNoYesNo
Altzheimer's DiseaseNoYesNo
InfertilityNoYesNo
Recurrent MiscarriageNoYesNo
Liver DiseaseNoYesNo
High Blood PressureNoYesNo
AsthmaNoYesNo
EpilepsyNoYesNo
Tourette's SyndromeNoYesNo
Still Born BabiesNoYesNo
Sudden Infant Death DefectsNoYesNo
Death before age 40NoYesNo
Addiction (indicate type)NoYesNo
Clinical OsteoporosisNoYesNo
I am interested in becoming an egg donor because:
 
Are you currently in a egg donor program elsewhere?
 Yes
 No
Have you ever donated your eggs before?
 Yes
 No
If yes, when did you donate?
How many eggs were retrieved?
 
Are you willing to share your photo with the oocyte recipient and allow us to post on CHR's donor database website?
 Yes
 No
Are you willing to travel to recipient clinic at no expense to you?
 Yes
 No
If I am chosen as an egg donor, I would like my oocyte recipient to know these things about my characteristics/personality and/or areas of talent:
Do you certify that your answers and explanations were voluntarily given?
 Yes
 No
Do you certify that your answers which were voluntarily given, are correct to the best of your knowledge?
 Yes
 No
Are you aware of any other health problems in your self, family or previous sexual partners that you have not already disclosed?
 Yes
 No
If yes, please indicate those problems you are aware of, that you have not already disclosed to us in this document:

 

I hereby certify that my answers and explanations, which were voluntarily given in this questionnaire, are correct. I understand that the answers used in this questionnaire will be used to determine my appropriateness as a donor and to help match me with a prospective recipient. I will allow CHR to share any of the information in this questionnaire with potential recipient couples except my identifying information. I am not aware of any problems in myself, my family, or my current or previous sexual partners that were not answered in the above questions.

Since the data will be encrypted, please allow 2 minutes after you click submit before moving to another page.

Rev. 4/30/10

Privacy Policy | Terms of Use | Designed and maintained by Busimed, Inc. | © 2010 CHR.