| Please submit Part I now (below) online. Part II, the Health History, may also be completed and submitted to us online, or printed and sent by postal mail, or you may choose to complete Part II with the assistance of the Donor Coordinator at your meeting with MyDonor. |
| Part I - OOCYTE Donor Physical and Personal Characteristics |
| *Date of birth: |
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| *Marital Status: |
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| *Ethnic Background: |
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| *Religion: |
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| *Highest Level of Education: |
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| *Occupation: |
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| *Do you have medical insurance coverage?
-Yes
-No |
| *Do you have hospital insurance coverage?
-Yes
-No |
| If yes, Insurance Company |
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| *Hobbies: |
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| *Interests: |
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| *Blood Type/Rh: |
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| *Tattoos? |
-Yes
-No |
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If yes, date received:
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| *Body Piercings? |
-Yes
-No |
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If yes, date received:
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| *Vaccines? |
-Yes
-No |
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If yes, Type and date received:
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| *Number of Children: |
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| *Number of Pregnancies: |
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| *Number of Miscarriages: |
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| *Number of Voluntary Terminations: |
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*List any previous surgical procedures you have undergone and the approximate dates:
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| *List any medications you are now taking: |
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| *List any allergies you may have: |
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| *Are your monthly cycles regular?
-Yes
-No |
| *Approximately
days between periods |
| *Approximately
days duration |
| *Do you smoke?
-Yes
-No |
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If yes, how much?
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| *Have you donated oocytes before?
-Yes
-No |
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If yes, when and where?
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| *How did you find out about MyDonor? |
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If you found MyDonor with a search engine, which one?
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If you heard of MyDonor at school, which school?
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| Overview of the Prospective OOCYTE Donor Characteristics |
| Yourself |
| *Race: |
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| *Religious Heritage: |
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| *Ethnic Heritage: |
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| *Height (ft/in): |
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| *Weight (lbs.): |
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| *Eye Color: |
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| *Hair Color: |
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| *Skin Tone: |
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| *Complexion: |
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| *Do you wear glasses for reading?
-Yes
-No |
| *Do you wear glasses for distance?
-Yes
-No |
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If yes, how long have you been wearing glasses?
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| *Do you have any hearing problems?
-Yes
-No |
| Your Father |
| *Race: |
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| *Religious Heritage: |
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| *Ethnic Heritage: |
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| *Height (ft/in): |
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| *Weight (lbs.): |
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| *Eye Color: |
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| *Hair Color: |
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| *Skin Tone: |
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| *Complexion: |
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| *Does he wear glasses for reading?
-Yes
-No |
| *Does he wear glasses for distance?
-Yes
-No |
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If yes, how long have he been wearing glasses?
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| *Does he have any hearing problems?
-Yes
-No |
| Your Mother |
| *Race: |
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| *Religious Heritage: |
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| *Ethnic Heritage: |
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| *Height (ft/in): |
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| *Weight (lbs.): |
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| *Eye Color: |
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| *Hair Color: |
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| *Skin Tone: |
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| *Complexion: |
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| *Does she wear glasses for reading?
-Yes
-No |
| *Does she wear glasses for distance?
-Yes
-No |
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If yes, how long has she been wearing glasses?
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| *Does she have any hearing problems?
-Yes
-No |
