Expanding patient knowledge...
from thought to conception... and beyond
Streamlining the Gift of Life Processes...
from thought to conception... and beyond

Donor Application Form

Tell us about yourself
1. Are you eligible to work in the United States?
2. Are you a US citizen or permanent resident?
3. What is your FIRST name?
4. What is your LAST name?
5. What is your email address?
6. What is your mailing address?
Street City State/Province Zip/Postal Code Country
7. How far away from our practice do you live?
8. What is the primary phone number (include area code) to use for contact and leaving messages?
Ext.
9. What is your date of birth?
10. What is your height?
11. What is your weight?
12. What is your eye color?
13. What is your natural hair color?
14. What race would you most likely be affiliated?
Other race or self-description of race
15. Are you adopted?
16. What is the ethnic origin of your mother? (e.g. French, Irish)
17. What is the ethnic origin of your father? (e.g. French, Irish)
18. How many years of college did you complete?
19. What is your current occupation?
20. Do you have medical insurance?
21. Have you been vaccinated in the past 12 months?
If yes, what were you vaccinated for?
22. Are you currently under a physicians care for any reason?
If yes, please explain.
23. List all medications that you have taken in the proceeding 12 months (prescription). Enter "N/A" in the first box if you have not taken medications.
Rx Medications Medication How Often Reason
1
2
3
4
5
6
7
24. List all current over-the-counter medications (including hormones, vitamins, aspirin, antacids, laxatives, herbal & sports supplements, performance-enhancing supplements including steroids, etc.). Enter "N/A" in the first box if you have not taken any OTC medications.
OTC Medications Medication How Often Reason
1
2
3
4
5
6
7
25. Do you or your family or relatives have birth defects, genetic diseases, or serious medical problems?
If yes, explanation required.
26. Do you or your family or relatives have any history of any significant emotional or psychological problems (depression, bipolar, ADD, etc)?
If yes, explanation required.
27. How long is your monthly menstrual cycle (first day of one period to first day of the next)? (In days)
28. Have you ever had trouble conceiving? If yes, when and why?
If yes, when and was the cause identified?
29. How many pregnancies have you had?
30. To how many children have you given birth?
31. How many cigarettes do you smoke per day?
32. When is the last time you had marijuana?
33. When is the last time you used other recreational or illicit drugs (cocaine, LSD, heroin, barbiturates, narcotics, opiates, amphetamines, hallucinogens, tranquilizers, PCP, steroids, or etc.)?
If yes, which one(s)?
34. Have you ever been convicted of a felony?
If yes, explanation required.
35. Does anyone in your family have a family history of alcoholism, drug use, abuse, or addiction?
If yes, please list who and additional details (such as currently struggling, in therapy, sober for 2 years, etc)
36. Have you applied or been screened to be an egg donor before?
If yes, provide the name and location of the donor program(s).
37. How many times have you donated?
38. Are you currently enrolled as an egg donor in another program?
39. Do you have other skills/hobbies/talents/interests (i.e. writing, reading, ability to do games or crossword puzzles, handcrafts)? Describe.
40. Please add additional comments or questions:
41. Are you currently pregnant or trying to get pregnant?
42. Are you currently breastfeeding?
43. What resources did you use and/or impacted your decision to apply?
eIVF.net Resolve
AFA (American Fertility Assn Physician
Insurance Company
Employer
Internet
TV News / Report
Seminar
Friend or Relative
Former / Current Patient
KRLD WABC
WZYZ Other
NY Times Time Magazine
LA Times Dallas Morning News
Other
Highway 75 635 and Luna
Loop 12 295 Southbound

Your privacy is very important to us. Information collected here will only be shared with Atlantic Reproductive Medicine which may contact you as a follow up.