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Egg Donor Application

If you are accepted by a family to act as an egg donor, in recognition of your time, effort, and commitment you will receive a competitive compensation of $7,000.

To start the process of becoming an egg donor, please take the time to accurately provide the information below. The best way to improve your chances of being selected as an egg donor is to complete the entire form. In selecting ancestry, please reflect on your family history prior to being American, i.e., russian, german, irish, african, chinese, etc. Also remember it's best if you live reasonably close to the Chicagoland. We appreciate your willingness to help others.

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  *  (mm/dd/yyyy)
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I heard about egg donation through:   
  A friend or another donor   Name:  
  A patient of RGI/IHR/CHR   Name:  
  Advertisement   Name:  
  Internet   
  
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:  
 
Select ancestry, percentage for 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
Associate's Degree
Graduate Study
Graduate Degree
      Masters
      MBA
      Ph.D.
      D.O.
      M.D.
      Law
Post Graduate Study
  Other       Enter Other:  
 
S.A.T. Scores:
 
Other Placement Scores:
 
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 you 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
Sepsis West Nile Virus
Vaccinia Creutzfeld-Jakob disease (CJD)
Chagas disease, protozoan parasite, T. cruzi  
 
Do you have an occupation with risk of radiation exposure or 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
 
What is your blood type?
 
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?
 
Are you current or former U.S. military or civilian (or dependent), who resided on Germany, Belgium, or Netherlands military base for 6 months or more between 1980-1990?
Yes
No
 
Are you current or former U.S. military or civilian military (or dependent), who resided on a Greece, Turkey, Spain, Portugal, or Italy military base for 6 months or more between 1980-1996?
Yes
No
 
Have you ever spent 5 or more cumulative years in Europe?
Yes
No
 
Did you spend 3 or more cumulative months in the U.K. between 1980-1996?
Yes
No
 
Have you received any blood transfusions or transfusions of blood products in the U.K. or France?
Yes
No
 
Have you or your sexual partner lived in Cameroon, Central African Republic, Chad, Congo, Guinea, Gabon, Niger, or Nigeria since 1977?
Yes
No
 
Have you ever received blood transfusions or other blood products in any of the African countries listed above?
Yes
No
 
Ever been diagnosed with dementia, or other diseases of the central nervous system?
Yes
No
 
Ever received a human pituitary-derived growth hormone?
Yes
No
 
Ever had a non-synthetic dura mater transplant?
Yes
No
 
Ever received any transplantation of living cells (xenotransplant), or had intimate
contact with any xenotransplant recipient?
Yes
No
 
 
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

 
Relative Alive?        Age/age death Height Weight Hair Color Eye Medical Issues Occupation Birthplace
Mother YN
Grandmother YN
Grandfather YN
Father YN
Grandmother YN
Grandfather YN
Sibling 1 YN
Sibling 2 YN
Your Child 1 YN
Your Child 2 YN
 
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.
 
Condition Self                 Family               Who in the Family?
Cleft PalateYesNoYesNo
Spina BifidaYesNoYesNo
Thyroid DiseaseYesNoYesNo
ClubfootYesNoYesNo
Mental RetardationYesNoYesNo
Down's SyndromeYesNoYesNo
Cystic FibrosisYesNoYesNo
Marfan SyndromeYesNoYesNo
AlbinismYesNoYesNo
Muscular DystrophyYesNoYesNo
Cancer (indicate type)YesNoYesNo
SchizophreniaYesNoYesNo
Clinical DepressionYesNoYesNo
Obsessive-Compulsive DisorderYesNoYesNo
ManiaYesNoYesNo
Tay Sachs DiseaseYesNoYesNo
Canavan's DiseaseYesNoYesNo
Hemolytic AnemiaYesNoYesNo
BlindnessYesNoYesNo
Hearing ImpairmentYesNoYesNo
Color BlindnessYesNoYesNo
Heart DiseaseYesNoYesNo
Parkison's DiseaseYesNoYesNo
HemochromotosisYesNoYesNo
High CholesterolYesNoYesNo
Sickle Cell AnemiaYesNoYesNo
HemophiliaYesNoYesNo
Huntington's DiseaseYesNoYesNo
DiabetesYesNoYesNo
Multiple SclerosisYesNoYesNo
Alzheimer's DiseaseYesNoYesNo
InfertilityYesNoYesNo
Recurrent MiscarriageYesNoYesNo
Liver DiseaseYesNoYesNo
High Blood PressureYesNoYesNo
AsthmaYesNoYesNo
EpilepsyYesNoYesNo
Tourette's SyndromeYesNoYesNo
Attention Deficit SyndromeYesNoYesNo
Still Born BabiesYesNoYesNo
Sudden Infant Death DefectsYesNoYesNo
HermaphrodismYesNoYesNo
Death before age 40YesNoYesNo
Addiction (indicate type)YesNoYesNo
Clinical OsteoporosisYesNoYesNo
chagasYesNoYesNo
 
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?
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 the 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 IHR 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.