Donor Questionnaire

"*" indicates required fields

1Physical Characteristics

2Medical History

3Sexual & Contraceptive History

4Reproductive History

5Family History

6Family Genetic History

7Family Genetic History cont.

8Family Genetic History cont.

9Family Genetic History cont.

10Family Ethnic History

11Personal History

12Personal History cont.

13Personal History cont.

14Personal History cont.

15Personal History cont.

16Personal History cont.

Physical Characteristics

Name*

Email*

Marital Status:*

Single

Partnered

Married

Divorced

Donor Date of Birth*

MM slash DD slash YYYY

Height*

ie: 5′ 6″

Weight*

Recent weight loss/gain?*

Yes

Lbs Gained or Lost?*

Number of Lbs Gained*

How Many Lbs Gained

Number of Lbs Lost*

How Many Lbs Lost

Are You?*

Right Handed

Left Handed

Ambidextrous

Bone Structure:*

Petite

Small

Medium

Complexion*

Fair

Light

Medium

Olive

Light Brown

Dark Brown

Tan ability:*

None

Easy

Medium

Dark

Skin Condition:*

Oily

Medium

Dry

Combination

Dimples?*

Yes

Where?*

(Dimples)

Eye Color:*

Blue

Brown

Light Brown

Dark Brown

Green

Hazel

Eye set:*

Narrow

Average

Wide

Eye Size:*

Small

Average

Large

Eye Shape:*

Round

Oval

Almond

Natural Hair Color:*

Light Blonde

Medium Blonde

Dark Blonde

Light Brown

Medium Brown

Dark Brown

Black

Red

Auburn

Hair Type:*

Curly

Wavy

Straight

Hair Texture:*

Fine

Medium

Coarse

Fullness:*

Thin

Medium

Thick

Have you had any periodontal or orthodontic work?*

Yes

If Yes, at What Age and What Procedure?*

ie. 15 year braces

Vision

Vision*

Fair

Good

Excellent

(without corrective lenses):

Do you wear glasses or contacts?*

Yes

If yes, are you:*

Nearsighted

Farsighted

Other (specify)

Other*

Prescription (If known):

Allergies

Do you have any Allergies?*

Yes

If yes, are they to:*

Food(s)

Medication(s)

Environmental

For each allergy, describe specific substance, reaction(s), and treatment:*

Substance:

Reaction(s):

Treatment:

Click Plus Icon to Add More.

Please list any allergies that you have outgrown:

Exercise

Exercise:*

None

Occasional

Regular

Type of Exercise:*

Diet

Diet:*

Non-vegetarian

Vegetarian

Vegan

Other

Other – Please describe*

Do you have any dietary restrictions?*

Yes

Dietary Restrictions*

What Restriction

Why

Click “+” to add more.

What is your caffeine cup usage in a week?*

Soda

Tea

Coffee

Energy Drinks

What best describes your alcohol consumption?*

Daily

Occasionally

Rarely

Never

Please describe*

Medical History

THIS PAGE WILL BE VIEWED BY INTENDED PARENTS

Have you had any surgical procedures or hospitalizations?*

Yes

Please Describe*

Type

Date

Click “+” icon to add more.

SEXUAL & CONTRACEPTIVE HISTORY

THIS PAGE WILL BE VIEWED BY INTENDED PARENTS

Sexual Orientation*

Heterosexual

Homosexual

Bisexual

Other

Other*

THIS PAGE WILL BE VIEWED BY INTENDED PARENTS

Have you ever been pregnant?*

Yes

Pregnancy*

Live Birth

Miscarriage

Ectopic

Termination

Miscarriage Date*

MM slash DD slash YYYY

Ectopic Date*

MM slash DD slash YYYY

Termination Date*

MM slash DD slash YYYY

Child(ren)

Child(ren)*

Date of Birth

Gender

Eye Color

Please Click + Icon to Add More Children. (Maximum of 5 Children)

Child(ren) – Part 2*

Hair Color

Complexion

Additional Information

Please Click + Icon to Add More Children. (Maximum of 5 Children)

THIS PAGE WILL BE VIEWED BY INTENDED PARENTS

Carefully review the following list of medical problems and identify which ones you or one of your family members have had. Please consider each condition carefully for each family member. Explain any conditions you check below, indicating which side of the family (maternal or paternal), the age at the time of onset, and any other pertinent information.

Siblings

Do you have any Siblings?*

Yes

How many siblings are in your immediate family (including half siblings)?*

Please enter a number less than or equal to 8.

Number of Brothers*

Please enter a number less than or equal to 4.

Number of Sisters*

Please enter a number less than or equal to 4.

Number of ½ Brothers*

Please enter a number less than or equal to 4.

Number of ½ Sisters*

Please enter a number less than or equal to 4.

Aunts / Uncles

Number of Maternal Aunts*

Number of Maternal Uncles*

Number of Paternal Aunts*

Number of Paternal Uncles*

Parents

Mother Intellectual/Academic Achievements

Mother Artistic/ Athletic Achievements

Father Intellectual/Academic Achievements

Father Artistic/ Athletic Achievements

Siblings

Sisters Intellectual/Academic Achievements

Sisters Artistic/ Athletic Achievements

Sister #2 Intellectual/Academic Achievements

Sister #2 Artistic/ Athletic Achievements

Sister #3 Intellectual/Academic Achievements

Sister #3 Artistic/ Athletic Achievements

Sister #4 Intellectual/Academic Achievements

Sister #4 Artistic/ Athletic Achievements

Half Sister #1 Intellectual/Academic Achievements

Half Sister #1 Artistic/ Athletic Achievements

Half Sister #2 Intellectual/Academic Achievements

Half Sister #2 Artistic/ Athletic Achievements

Half Sister #3 Intellectual/Academic Achievements

Half Sister #3 Artistic/ Athletic Achievements

Half Sister #4 Intellectual/Academic Achievements

Half Sister #4 Artistic/ Athletic Achievements

Brothers Intellectual/Academic Achievements

Brothers Artistic/ Athletic Achievements

Brother #2 Intellectual/Academic Achievements

Brother #2 Artistic/ Athletic Achievements

Brother #3 Intellectual/Academic Achievements

Brother #3 Artistic/ Athletic Achievements

Brother #4 Intellectual/Academic Achievements

Brother #4 Artistic/ Athletic Achievements

Half Brother #1 Intellectual/Academic Achievements

Half Brother #1 Artistic/ Athletic Achievements

Half Brother #2 Intellectual/Academic Achievements

Half Brother #2 Artistic/ Athletic Achievements

Half Brother #3 Intellectual/Academic Achievements

Half Brother #3 Artistic/ Athletic Achievements

Half Brother #4 Intellectual/Academic Achievements

Half Brother #4 Artistic/ Athletic Achievements

FAMILY GENETIC HISTORY

THIS PAGE WILL BE VIEWED BY INTENDED PARENTS

Describe biological family members according to the following characteristics. Use natural eye and hair color; fair/dark, etc. complexion. If they are deceased, please list cause of death. Please do not put “natural” as a cause of death. If unknown, write “unknown.” Please do not put “natural” as a cause of death. If unknown, write “unknown.”

Sisters

Sister 1 – Part 1*

Eye Color

Hair Color

Complexion

Height

Weight

Sister 1 – Part 2*

Bone Type

Occupation I Education

Age if living

Age at time of death

Cause of death

Sister 2 – Part 1*

Eye Color

Hair Color

Complexion

Height

Weight

Sister 2 – Part 2*

Bone Type

Occupation I Education

Age if living

Age at time of death

Cause of death

Sister 3 – Part 1*

Eye Color

Hair Color

Complexion

Height

Weight

Sister 3 – Part 2*

Bone Type

Occupation I Education

Age if living

Age at time of death

Cause of death

Sister 4 – Part 1*

Eye Color

Hair Color

Complexion

Height

Weight

Sister 4 – Part 2*

Bone Type

Occupation I Education

Age if living

Age at time of death

Cause of death

1/2 Sister 1 – Part 1*

Eye Color

Hair Color

Complexion

Height

Weight

1/2 Sister 1 – Part 2*

Bone Type

Occupation I Education

Age if living

Age at time of death

Cause of death

1/2 Sister 2 – Part 1*

Eye Color

Hair Color

Complexion

Height

Weight

1/2 Sister 2 – Part 2*

Bone Type

Occupation I Education

Age if living

Age at time of death

Cause of death

1/2 Sister 3 – Part 1*

Eye Color

Hair Color

Complexion

Height

Weight

1/2 Sister 3 – Part 2*

Bone Type

Occupation I Education

Age if living

Age at time of death

Cause of death

1/2 Sister 4 – Part 1*

Eye Color

Hair Color

Complexion

Height

Weight

1/2 Sister 4 – Part 2*

Bone Type

Occupation I Education

Age if living

Age at time of death

Cause of death

Brothers

Brother 1 – Part 1*

Eye Color

Hair Color

Complexion

Height

Weight

Brother 1 – Part 2*

Bone Type

Occupation I Education

Age if living

Age at time of death

Cause of death

Brother 2 – Part 1*

Eye Color

Hair Color

Complexion

Height

Weight

Brother 2 – Part 2*

Bone Type

Occupation I Education

Age if living

Age at time of death

Cause of death

Brother 3 – Part 1*

Eye Color

Hair Color

Complexion

Height

Weight

Brother 3 – Part 2*

Bone Type

Occupation I Education

Age if living

Age at time of death

Cause of death

Brother 4 – Part 1*

Eye Color

Hair Color

Complexion

Height

Weight

Brother 4 – Part 2*

Bone Type

Occupation I Education

Age if living

Age at time of death

Cause of death

1/2 Brother 1 – Part 1*

Eye Color

Hair Color

Complexion

Height

Weight

1/2 Brother 1 – Part 2*

Bone Type

Occupation I Education

Age if living

Age at time of death

Cause of death

1/2 Brother 2 – Part 1*

Eye Color

Hair Color

Complexion

Height

Weight

1/2 Brother 2 – Part 2*

Bone Type

Occupation I Education

Age if living

Age at time of death

Cause of death

1/2 Brother 3 – Part 1*

Eye Color

Hair Color

Complexion

Height

Weight

1/2 Brother 3 – Part 2*

Bone Type

Occupation I Education

Age if living

Age at time of death

Cause of death

1/2 Brother 4 – Part 1*

Eye Color

Hair Color

Complexion

Height

Weight

1/2 Brother 4 – Part 2*

Bone Type

Occupation I Education

Age if living

Age at time of death

Cause of death

Mother

Mother*

Eye Color

Hair Color

Complexion

Height

Weight

Mother – Part 2*

Bone Type

Occupation I Education

Age if living

Age at time of death

Cause of death

Father

Father*

Eye Color

Hair Color

Complexion

Height

Weight

Father – Part 2*

Bone Type

Occupation I Education

Age if living

Age at time of death

Cause of death

Grandmother

Maternal Grandmother

Eye Color

Hair Color

Complexion

Height

Weight

Maternal Grandmother – Part 2

Bone Type

Occupation I Education

Age if living

Age at time of death

Cause of death

Paternal Grandmother

Eye Color

Hair Color

Complexion

Height

Weight

Paternal Grandmother – Part 2

Bone Type

Occupation I Education

Age if living

Age at time of death

Cause of death

Grandfather

Maternal Grandfather

Eye Color

Hair Color

Complexion

Height

Weight

Maternal Grandfather – Part 2

Bone Type

Occupation I Education

Age if living

Age at time of death

Cause of death

Paternal Grandfather

Eye Color

Hair Color

Complexion

Height

Weight

Paternal Grandfather – Part 2

Bone Type

Occupation I Education

Age if living

Age at time of death

Cause of death

Cancer

Breast Cancer*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Colon or Intestinal Cancer*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Lung Cancer*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Ovarian or Uterine Cancer*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Prostate or Testicular Cancer*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Skin Cancer*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Stomach Cancer*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Thyroid Cancer*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Blood (e.g. leukemia) Cancer*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Other Cancer*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Heart

Stroke*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Heart Attack*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Congenital Heart Disease*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Heart Disease or Defect*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Hardening of the Arteries*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

High Blood Pressure*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

High cholesterol level*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Blood

Anemia*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Sickle-Cell Anemia*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Factor V Leiden thrombophilia (Blood clots or strokes)*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Hemophilia or other Bleeding/Clotting Disorders such as Von Willebrand’s Disease*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Immune Deficiency*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Leukemia*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Hodgkin a or nonHodgkin lymphoma*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

HIV*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Thalassemia*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Other Blood Disorder*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Respiratory

Asthma*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Hay Fever*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Emphysema*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Tuberculosis*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Pneumonia*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Other Lung Disease*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Gastro-Intestinal

Appendicitis*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Ulcer of Stomach or Duodenum*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Gallstones*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Hepatitis A, B, or C*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Cirrhosis of the Liver*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Other Liver Disease*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Ulcerative Colitis*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Crohns Disease*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Reflux*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Rectal Disorder*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Inflammatory Bowel Disease (IBS)*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Any other problem of the digestive system*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Metabolic / Endocrine

Diabetes requiring insulin therapy*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Diabetes not requiring insulin therapy*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Childhood Diabetes*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Thyroid disorder*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Goiter*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Hypoglycemia*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Adrenal Dysfunction or Disorder*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Graves Disease*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Obesity*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Urinary

Kidney Problems*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Polycystic Kidney Disease*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Other disease/ defect of urinary tract (urethra, bladder, ureter)*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Genital / Reproductive

Hermaphroditism/ Ambiguous Genitals*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Hypospadias or undescended testicle*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Uterine Fibroids*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Ovarian Cysts or Ruptured*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Lumps or Cysts in Breast or Discharge*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Polycystic Ovarian Syndrome (PCOS)*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Pelvic Inflammatory Disease (PID)*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Endometriosis*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Reproductive Outcomes

2 or more Miscarriages*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Stillborn*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Premature Menopause*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Death of a newborn infant*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Childhood death*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Birth defects*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Infertility*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Premature Birth*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Neurogical

Migraines*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Mentally Handicaped*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Senility or Mental Deterioration before age 50*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Multiple Sclerosis*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Cerebral Palsy*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Neurofibromatosis*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Epilepsy / Seizures*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Asperger’s*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Autism*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Alzheimer’s Disease/Dementia*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Hydrocephalus*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Tuberous Sclerosis*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Parkinson’s Disease*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Huntington’s or Wilson’s Disease*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Tourette’s syndrome*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Other diseases of the nervous system*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Mental Health

Anxiety/Panic Attacks*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Anorexia/Bulemia/other eating disorders*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Depression*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Schizophrenia*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

ADD & ADHD*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Manic Depressive or Bipolar Disorder*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Other mental health disorder requiring hospitalization*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Suicide Attempt*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Other mental health problems that warranted counseling (please list)*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Muscle / Bone / Joint

Muscular Dystrophy*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Gout*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Osteogenesis imperfecta (brittle bone disease)*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Loss of Muscle*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Osteoporosis*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Marfan Syndrome*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Arthritis*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Rheumatoid or Juvenile Arthritis*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Spinal Muscular Atrophy*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Hereditary Low Back Disorder or Deformity of Spine*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Reiter’s Disease*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Scoliosis*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Other Chronic Muscle Disease*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Lupus (systemic lupus erythematosis – SLE)*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Sight / Sound Smell

Deafness before age 60*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Blindness*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Cataracts before age 50*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Color Blindness*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Severe Myopia*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Glaucoma*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Retinoblastoma*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Retinitis Pigmentosa*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Deviated Septum*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Any other Sensory Disorder*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Skin

Acne*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Albinism*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Eczema*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Excessive Facial Hair (Hirsutism)*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Pigmentation Disorders*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Psoriasis*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Neurofibromatosis*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Lymphoma*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Infectious Skin Disease*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Congenital Abnormalities/ Birth Defects

Cleft Lip / Palate*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Congenital Hip Problems*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Club Feet*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Heart Defect*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Hearing Problems*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Spina Bifida -Neural Tube (open spine)*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Microcephaly*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Other*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Chromosomal Abnormalities

Down Syndrome*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Tay-Sachs*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Other (i.e. Turner, Fragile X, Klinefelter’s etc.)*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Other

Alcoholism*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Drug abuse, Misuse or Addiction*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Premature degeneration of any organ system*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

Any other condition not mentioned above*

None

Self

Mother

Father

Sibling

Grandparents

Aunt/ Uncle

Cousin

Explanation (which side of family, age of onset, etc.)*

FAMILY ETHNIC HISTORY

THIS PAGE WILL BE VIEWED BY INTENDED PARENTS

Mother Primary Ethnic Origin*

(no more than 3)

Father Primary Ethnic Origin*

(no more than 3)

(MGM=Maternal Grandmother, MGF=Maternal Grandfather; PGM=Paternal Grandmother, PGF=Paternal Grandfather)

African American

MGM

MGF

PGM

PGF

Eastern European (Ashkenazi) Jewish, Russia Romania etc.

MGM

MGF

PGM

PGF

Central European (Hungary, Poland, Romanian Czech Republic) etc.

MGM

MGF

PGM

PGF

Mediterranean – Southern Europe (Greece, Italy, Portugal Spain) etc.

MGM

MGF

PGM

PGF

Western Europe (Germany, Ireland, UK, Switzerland) etc.

MGM

MGF

PGM

PGF

Hispanic

MGM

MGF

PGM

PGF

Middle Eastern

MGM

MGF

PGM

PGF

Asian (includes India)

MGM

MGF

PGM

PGF

Native American

MGM

MGF

PGM

PGF

Have you done any ancestry genetic testing?*

Yes

Please explain*

PERSONAL HISTORY

THIS PAGE WILL BE VIEWED BY INTENDED PARENTS

Religion Born Into:*

Religion Practiced:*

SAT:*

Did Take

Did Not Take

SAT Score:*

SAT Max Score*

1600

2400

ACT*

Did Take

Did not Take

ACT Score:*

Education*

High School

Some College

Completed college, degree

Completed advanced, degree

Currently in college, pursuing degree

Completed college, degree in*

Technical

GPA*

Completed advanced, degree in*

Completed college, degree in*

Masters

Doctorate

GPA*

Currently in college, pursuing degree in*

Technical

Master

Doctorate

GPA*

Additional Information

How many languages do you speak?*

Which one(s)?*

Current Occupation*

How long have you been at your current job?*

What are your present and future professional goals?*

Athletic Abilities?*

Artistic Talents?*

Musical Talent or Instrument?*

Year’s of Experience?*

What is your favorite sport?*

What is your favorite book?*

What is your favorite food?*

What is your favorite movie?*

What is your favorite color?*

Hobbies?*

What are your academic strengths?*

What are your academic weaknesses?*

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

Describe your personality, temperament, social abilities, and character:*

Describe your personality and temperament as a child:*

What was your favorite thing to do as a child?*

Growing up as a child, what were you taught to value?*

How were you in comparison to other children?*

Describe your personality and temperament as a teenager:*

Did you have any problems as a child and/ or as a teenager? Explain:*

What were your ambitions/goals as a teenager?*

What were your academic strength and weaknesses as a teenager?*

List the 3 achievements you are most proud of:*

What is one of your most memorable moments and why?*

Who was the most important influence on you and why?*

If you could change one thing about yourself, what would it be and why?*

Is there a person alive or dead whom you admire and why?*

What would you do on a “perfect” day if you could do anything you wanted?*

Additional Information about yourself:

Reasons for wanting to donate eggs:*

If you could pass on a message to the recipient(s) of your eggs what would that message be?*

If you could write a message to the child born through your participation as an egg or donor for when he/she turns 18 years old, what would you tell him/her?*