Egg Donor Application

Transcription

1 Egg Donor Application Name: Outgoing and Caring Animal Lover Date filled out: 09/12/2011 Date of Birth: July 1990 Marital Status: Single Engaged Married Divorced Widowed Mailing Address: Palm Beach County, Florida Would you be willing to travel out of the state to donate? Yes No (Your travel costs will be paid by your Loving Couple) Are there dates when you cannot travel? Yes No : Do you have a valid driver s license? Yes No If yes, please attach a copy of your driver license (front and back) Do you own a car? Yes No Prior Donor History: Have you ever been an egg donor before? Yes No When? / Where? When? / Where? When? / Where? (Note: The Loving Couple s reproductive endocrinologist will require copies of the records from each prior donation cycle) About the Donation: Would you prefer to do an anonymous donation? Yes No Either Do you prefer, or are you willing to talk to or meet the Loving Couple? Yes No : I do not prefer to talk to the couple or meet them but if they would like to talk to me or meet me then I will do it to make the couple happy or feel more comfortable. Would you be willing to meet a child conceived as a result of your donation? Yes No : Are there any recipients that you do not want to donate to? Yes No : Are you willing to donate to all ethnicities? Yes No If not, please explain: Have you told any family or friends about your decision to donate? Yes No If yes, who have you told and are they supportive? I told my boyfriend, my father, and my father's girlfriend. My father's girlfriend thought it was a great idea and was very supportive. My boyfriend and my father did not like the idea at first and they both asked: "You want your

2 kids running around somewhere in the world?" I talked things over with them and then they became supportive as well. I don t consider myself a mother by donating my eggs because a mother is there for the child and guides it through life. I consider myself a person helping out someone else and I am helping a couples dream come to life. Physical Characteristics: Race: White Height: 5 feet 7inches Natural eye color: Blue Weight: 170pounds Please choose one that best describes your skin complexion: Fair Medium Dark Natural hair color: Blonde Please choose one that best describes your natural hair: Texture/volume: Thin Medium Thick Type: Straight Wavy Curly Please choose one that best describes your body type: Small Medium Large Other Blood Type: Were you adopted? Yes No Mother s ethnic origin: White Father s ethnic origin: White Religion by birth: Catholic Religion now: Christian Pregnancy/Sexual History Have you been pregnant before? Yes No If yes, please fill out the following: Year and Sex of Child, Your age Duration Complications/Healthy/Miscarriage Age of Child Is there a history of infertility in your family? Yes No Not Sure : Personal Health History Do you currently have any allergies? Yes No If yes, are they to: (check all that apply) Food Drugs Environment Other 2

3 Please list specific substances and reaction(s) produced: Do you have any allergies that you have outgrown? Yes No How is your vision without glasses or contact lenses? Poor Fair Good Excellent Do you wear glasses or contact lenses? Yes No If yes, which? Glasses Contact lenses Both Do you have normal hearing? Yes No If no, please explain What is the condition of your teeth? Poor Fair Good Excellent Please explain Have you ever smoked cigarettes? Yes No If yes: Current smoker Former smoker Age started smoking Number of cigarettes per day Age stopped smoking Do you take any over-the-counter medications at the present time? Yes No If yes, please list the medications and the reason you are taking them Do you take any prescription medication at the present time? Yes No If yes, please list the medications and the reason you are taking them Have you gained or lost more than 10 pounds in the past year? Yes No Have you ever participated in mental health counseling? Yes No What kind of alcoholic beverages do you drink? Beer. How many drinks do you consume per day? 0 per week?1-2 per month?4-6 Have you ever used intravenous drugs? Yes No Have you ever been with a partner who may have used intravenous drugs? Yes No Have you had and/or been treated for a substance-alcohol abuse/addition problem? Yes No 3

4 Do you have any legal cases pending including as a witness? Yes No Have you ever filed for bankruptcy? Yes No Have you ever been convicted of a crime? Yes No : Do you or anyone in your family have or been diagnosed with or a carrier of a genetic disease or illness, mental or physical? (Including learning disabilities) Yes No Has any member of your immediate family ever smoked, drank alcohol to excess, or used illegal substances? To what extent are any of these, or have any of these ever been a problem? No. Have twins or other multiple births occurred in your family? Yes No Education and Work Please check all that apply: Completed high school GPA: 2.9 (4 point scale) Completed some college Area of study: GPA: Currently in college Area of study: GPA: Completed college/degree GPA: Currently pursuing post graduate degree Area of study: GPA: Completed advanced degree Area of study: GPA: What is your occupation? Assistant Manager for a high-end gift registry company. How long have you been employed in this occupation? 9 months. If less than 5 years, what was your prior occupation? Office Assistant. 4

5 Languages you speak? English Individual questions Mark those traits which apply Eastern European Western European Scandinavian Mediterranean South/Central American Middle eastern/ Other Arab Jewish Ivy League Avid: Animal Lover Cook Reader Sports Enthusiast Traveler Accomplished: Artist Athlete Dancer Musician Singer Your personality and character (Please check all that apply): Extrovert Shy Slight extrovert Quiet Introvert Passive Slight Introvert Sensitive Aggressive Moody Assertive Dependent Independent Warm Happy Lonely Other qualities or personality traits: I am also a thrill seeker, people pleaser, outgoing, humorous, family oriented and adventurous. I am also patient and I am a leader, not a follower. I make my own decisions. Why do you want to be an egg donor? I want to be an egg donor because I want to help other women and couples who are not able to have children. I love the feeling of knowing I can help make a person's dream come true. I also understand that this whole 5

6 process is very real. My best friend is not able to have children. She was pregnant two seperate times but both pregnancies failed because the egg grows outside of her uterus. And if it ever came down to it I would donate my eggs to her as well. She is one of the reasons I have decided to donate my eggs. If I was not able to have children I would hope there would be someone who would do the same thing for me. I do not plan on having kids for at least another year so I am more than happy to help change someones life for the better. What do you like most about yourself? I like that I am outgoing and caring. I also like that I am creative and I don t need other people to entertain me. But I would have to say I like my personality the most. I'm so glad that I maintain my optimism and good humor throughout any kind of situation and turn a bad situation I into a good one. I also like that I am not afraid to speak my mind and I always believe in a better tomorrow. What are your personal interests and the activities you enjoy? My personal activities and interests consist of riding and caring for my horses, tanning, bowling, going to the beach, shopping until I drop and spending time with family. I also love to ride my four wheeler (ATV), go camping, fishing, watch football, go to car shows and go to drag races. I pretty much love to do anything that is outdoors. I am an adrenaline junkie! I love roller coasters and anything that gets my blood pumping! One of my favorite things to do is go to rodeos. My boyfriend rides bulls so it is always fun to go watch him ride. Of course it keeps me on the edge of my seat because he could get hurt but in a strange way that is also part of the fun. I also love scrapbooking and doing any type of arts and crafts. What are your talents and/or special skills? One of my skills is being creative. I love working on new projects and I enjoy making things for people. Another skill I have is being a great secret keeper. I like that friends and family come to me for help and advice and it makes me feel good to know they trust me enough to tell me things they wouldn t want anyone else to know. And I would say teaching is another skill I have. I enjoy teaching my younger brothers and sisters new things and I am appreciative I have the patience to do that. What are you doing now in your life? Enjoying it and living it to the fullest! I am an Assistant Manager for a bridal registry company. I work six days a week and I work a minimum of 35 hours. I have been working here for 9 months. I am currently saving up money so I can go to college to become a sheriff or an emergency medicine doctor. I have not decided yet. I am also currently saving up money to get an apartment with my boyfriend. And I volunteer at least twice a week at a dog rescue ranch walking, playing, and bathing dogs who are sick or have been abused and/or abandoned. What are your future goals? I plan on starting school within the next few months and start working on my Associates Degree until I figure out which career I want to pursue. I still live with my father and one of my goals is to move out with my boyfriend by the end of this year. I also plan on getting engaged and having two kids of my own within the next 6

7 year or two. Another goal I have is to eventually become manager or supervisor at my job. I have been going above and beyond and working hard to get these goals accomplished. What else would you like the recipient(s) of your donation to know about you? I am the oldest of four children. I have an 11 year old brother named Jessy, a 5 year old sister named Adriana, and a 1 year old brother named Nikolas. I have three horses. A brown thoroughbred named Goofy, another brown thoroughbred named Bullseye, and a white mustang named Pronto. I am very family oriented and I love children. I also love to cook and clean. I still enjoy watching cartoons, and my favorite football team is the Miami Dolphins. Family Characteristics Biological Mother: Age if alive:41 Medical problems or cause of death: (does she take any daily medications?) N/A Occupation and/or schooling (before retirement): Medical Billing and Coding Natural eye color: Green Natural hair color (before the gray): Brown Height: 5feet 3inches Weight: 125pounds Biological Father: Age if alive: 43 Medical problems or cause of death: (does he take any daily medications?) N/A Occupation and/or schooling (before retirement): Manager/Supervisor for ProShell Construction Company. Natural eye color: Brown. Natural hair color (before the gray): Brown. Height: 5 feet 9inches Weight: 185pounds 7

8 Biological Maternal Grandmother: Age if alive: 58 Medical problems or cause of death: (does she take any daily medications?) N/A Occupation and/or schooling (before retirement): Waitress Natural eye color: Blue Natural hair color (before the gray): Blonde Height: 5feet 10inches Weight: 175pounds Biological Maternal Grandfather: Age if alive:64 Medical problems or cause of death: (does he take any daily medications?) N/A Occupation and/or schooling (before retirement): Construction. Natural eye color: Brown Natural hair color (before the gray): Brown. Height: 6feet 0inches Weight: pounds Biological Paternal Grandmother: Age if alive: 64 Medical problems or cause of death: (does she take any daily medications?) N/A Occupation and/or schooling (before retirement): Waitress Natural eye color: Blue Natural hair color (before the gray): Brown Height: 5feet 4inches Weight: 140pounds Biological Paternal Grandfather: 8

9 Age if alive:66 Medical problems or cause of death: (does he take any daily medications?) N/A Occupation and/or schooling (before retirement): Taxi Driver Natural eye color: Brown Natural hair color (before the gray): Brown Height: 5feet 10inches Weight: 210pounds Sibling: #1 Male Female Age if alive: 11 Medical problems or cause of death: (does he/she take any daily medications?) N/A Occupation and/or schooling (before retirement): Elementary School Natural eye color: Brown Natural hair color (before the gray): Blonde Height: feet inches Weight: pounds Sibling: #2 Male Female Age if alive: 5 Age at death:n/a Medical problems or cause of death: (does he/she take any daily medications?) N/A Occupation and/or schooling (before retirement): Elementary School Natural eye color: Blue Natural hair color (before the gray): Brown Height: feet inches Weight: pounds Sibling: #3 Male Female 9

10 Age if alive: 1 Medical problems or cause of death: (does he/she take any daily medications?) N/A Occupation and/or schooling (before retirement): N/A Natural eye color: Brown Natural hair color (before the gray): Brown Height: feet inches Weight: pounds 10