Donor Annual Update

1Personal History

2Sexual & Contraceptive History

3Reproductive History

4COVID-19 Vaccination

5Family Medical History

PERSONAL HISTORY

THIS PAGE WILL BE VIEWED BY INTENDED PARENTS

Name(Required)

YOUR NAME WILL BE REDACTED PRIOR TO BEING VIEWED BY THE INTENDED PARENT (for our record keeping only)

First Last

Marital Status:(Required)

Single

Partnered

Married

Divorced

Height

ie: 5′ 6″

Weight(Required)

Recent weight loss/gain?(Required)

Yes

Lbs Gained or Lost?(Required)

Number of Lbs Gained(Required)

How Many Lbs Gained

Number of Lbs Lost(Required)

How Many Lbs Lost

Lifestyle

Exercise:(Required)

None

Regularly

Occasionally

Type of Exercise:

Diet:(Required)

Non-vegetarian

Vegetarian

Vegan

Other Diet Type

Do you have any dietary restrictions(Required)

What is your caffeine cup usage in a week?(Required)

Soda

Tea

Coffee

Energy Drinks

What best describes your alcohol consumption?(Required)

Regularly

Occassionally

Rarely

Never

How many drinks do you usually consume in a week?(Required)

Do you currently smoke?(Required)

Never

Cigarettes

Marijuana

E cigarettes

Other

Other(Required)

If so, how often?(Required)

Regularly

Occasionally

Rarely

If yes, how many per day(Required)

Medical History

Are you currently under a physician’s care for any reason?(Required)

Yes

If yes, please explain:(Required)

In the past 12 months, have you been seen by psychiatrist, psychologist, or any other mental health professional?(Required)

Yes

If yes, please explain for what, how long, & if medication is needed.(Required)

Have you had any serious illness in the past 12 months?(Required)

Yes

If yes, please describe:(Required)

Please list any surgical procedures or hospitalizations in the past 12 months:(Required)

List all prescription medications that you have taken in the past 12 months.(Required)

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Medication

How Often

Reason

List all current over-the-counter medications (include hormones, vitamins, aspirin, antacids, laxatives, herbal & sports supplements, performance-enhancing supplements including steroids, etc.):(Required)

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Medication

How Often

Reason

Have you had a blood transfusion in the past 12 months?(Required)

Yes

If yes, when and why?(Required)

Have you ever been refused or denied as a blood donor in the past 12 months?(Required)

Yes

If yes, why?(Required)

In the past 12 months, have you used recreational or illicit drugs (cocaine, marijuana, LSD, heroin, barbiturates, narcotics, opiates, amphetamines, hallucinogens, tranquilizers, PCP, steroids, or etc.)?(Required)

Yes

If yes, which one (s) and when did you last use them?(Required)

In the past 12 months, have you had any problems with the law (i.e. DUI, incarcerated, custody issues, lawsuits)?(Required)

Yes

If yes, please explain(Required)

Please list any arrests, convictions, sentences, etc.:(Required)

Do you sleep well?(Required)

Yes

If no, how do you manage this?(Required)

In the past 12 months, have you had any body piercings or tattoos?(Required)

Yes

If yes, please list and describe all your tattoos and body piercings in the past 12 months:(Required)

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Date

Description

Location on Body

Sterile Needles Used?

Education

Choose College Education(Required)

Complete College Degree

Completed Advanced Degree

Currently in College Pursuing Degree

Not In School

Completed college, degree in(Required)

Completed college, degree:(Required)

Technical

College Degree GPA(Required)

Completed advanced, degree in(Required)

Completed advanced, degree:(Required)

Masters

Doctorate

Advanced Degree GPA(Required)

Currently in college, pursuing degree in(Required)

Currently in college, pursuing degree:(Required)

Technical

Master

Doctorate

Current GPA(Required)

Additional Information

Career

Current Occupation(Required)

How long have you been at your current job?(Required)

Future career goals?(Required)

About You

Athletic Abilities?(Required)

Artistic Talents?(Required)

Musical Talent or Instrument?(Required)

Years of Experience?(Required)

What is your favorite sport?(Required)

What is your favorite book?(Required)

What is your favorite food?(Required)

What is your favorite movie?(Required)

What is your favorite color?(Required)

Hobbies?(Required)

Any additional interesting information about yourself you would like to share?(Required)

Other skills, talents, or interests (i.e. writing, reading, ability to do games or crossword puzzles, or handcrafts)?(Required)

SEXUAL & CONTRACEPTIVE HISTORY

THIS PAGE WILL BE VIEWED BY INTENDED PARENTS

Sexual Orientation:(Required)

Heterosexual

Homosexual

Bisexual

Other

Other Sexual Orientation(Required)

Number of sexual partners the in last 12 months:(Required)

Length of current relationship:(Required)

Years

Months

Current form of contraception:(Required)

IUD

Diaphragm

Condom

Birth Control Pills

Rhythm

Depo-Provera

Tubal Ligation

Abstinence

Other

Other(Required)

Date of last Pap Smear:(Required)

MM slash DD slash YYYY

Result:(Required)

REPRODUCTIVE HISTORY

THIS PAGE WILL BE VIEWED BY INTENDED PARENTS

In the past 12 months, have you been pregnant?(Required)

Yes

Type of Pregnancy(Required)

Miscarriage

Ectopic

Live Birth

Miscarriage Date(Required)

MM slash DD slash YYYY

Ectopic Date(Required)

MM slash DD slash YYYY

Live Birth Date(Required)

MM slash DD slash YYYY

If live birth, please provide the following information(Required)

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Gender

Weeks pregnant at time of delivery

Type of delivery

Complications

Length/Weight

Children

Age

Gender

Eye Color

Hair Color

Body Type

Personalility

Children – Set 2

Artistic Ability

Athletic Ability

Wears Glasses

Medication

Academic Performance

Additional Information

COVID-19 VACCINATION

THIS PAGE WILL BE VIEWED BY INTENDED PARENTS

Have you ever received a dose of COVID-19 vaccine in the past 12 months?(Required)

Yes

If yes, which vaccine product did you receive?(Required)

Pfizer-BioNTech

Moderna

Janssen (Johnson & Johnson)

Another Product:

Another Product:(Required)

FAMILY MEDICAL HISTORY

THIS PAGE WILL BE VIEWED BY INTENDED PARENTS

Have you done Ancestry testing in the past 12 months?(Required)

Yes

If YES, could you please provide a copy of the results?(Required)

Yes

Has there been any significant changes in the physical and mental health of your immediate family members in the past 12 months?(Required)

If deceased, please note the cause of death.

Yes

Mother:

Father:

Sibling(s):

Paternal Grandfather:

Paternal Grandmother:

Maternal Grandmother:

Maternal Grandfather:

Aunt(s):

Uncle(s):