 |
| 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? |
|
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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 |
 |
 |
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
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Rev. 4/30/10
|