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 the Chicagoland or New York City area 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
If yes, when did you last use injectable drugs?
Sexual Behavior:
I have worked as a prostitute in the past
I have engaged in homosexual activities
I have engaged in heterosexual activity with a prostitute within the previous six months
I engage in sexual activities with more than one partner on regular basis
I consider myself to be bisexual
I consider myself to be homosexual
I consider myself to be heterosexual
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
Have you ever been diagnosed as having any of the following (please check all that apply)
Depression
Schizophrenia
Manic Depression
Obsessive-Compulsive Disorder
Mania
Anorexia or Bulimia
Self Mutilation

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
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
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
Have you had intercourse with a bisexual or homosexual partner?
  Yes
   No
Have you had intercourse without the use of a condom in the last year?
  Yes
   No
Have any of your past or present sexual partners shown evidence of having HIV infection?
  Yes
   No
Have you ever been with a sexual partner who tested positive for a sexually transmitted disease?
  Yes
   No
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 had any of the following? (check all that apply):
Sexually Transmitted Disease Chlamydia
AIDS Condyloma (Human Papaloma Virus)
Ureaplasma/Mycoplasma Autoimmune Disorder
Syphilis Ovarian Cysts
Multiple Sclerosis Alzheimer's Disease
Tuberculosis Herpes Simplex Virus I or II
Abnormal Pap Smear Cancer
Hepatitis A, B or C Endometriosis
Fibroids Pelvic Inflammatory Disease
Hypertension Endocrine Disease
Do you have an occupation with risk of exposure to radiation or other chemicals that could be harmful to your health?
  Yes
   No
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
Have you ever received a blood transfusion or other blood products at any time in your life?
  Yes
   No
If yes, when did this happen?
Have you acquired a tattoo within the last year?
  Yes
   No
If yes, when did you get your newest tattoo?
Have you ever had an animal bite or rabies?
  Yes
   No
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

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