- Donor ID #: <%= id %>
- Age: <%= age %>
- City: <%= temp_region %>
- State: <%= state %>
- Education: <%= education_degree %>
- Height: <%= height_foot %>''<%= height_inch %>'
- Weight: <%= weight %>lbs
- Eye Color: <%= eye_color %>
- Hair Color: <%= hair_color %>
- Willing to travel: <%= will_travel %>
- Countries ancestors from: <%= origin_ancestors %>
- Religion: <%= religion %>
- Marital status: <%= marital_status %>
- Number of pregnancies: <%= num_pregnancies %>
- Blood type: <%= bloodtype %>
- Dominant hand: <%= dominant_hand %>
- Number of children: <%= num_children %>
- Birth place: <%= birthplace %>
- Occupation: <%= occupation %>
- Glasses: <%= eyes_glasses %>
- Astigmatism: <%= eyes_astigmatism %>
EYES
- Color: <%= hair_color %>
- Character: <%= hair_character %>
HAIR
- Tone: <%= skin_tone %>
- Acne: <%= skin_acne %>
SKIN
How would you describe your childhood?
<%= childhood %>
Who has been the most influential person in your life and how has this person affected you?
<%= influential_person %>
Please describe the types of responsibilities and jobs you have performed including church, family and volunteering.
<%= responsibilities %>
What accomplishments (awards, skills) in your life are you especially proud of?
<%= accomplishments %>
Describe athletic abilities and physical activities you engage in:
<%= physical_activity_excell %>
How would you describe yourself? Including personality and temperament.
<%= desc_yourself %>
Please describe other skills or talents do you have (painting, writing, ability to do games, crossword puzzles, handcrafts, etc.)
<%= skills %>
Instrument you play, years experience, level of proficiency:
<%= instrument %>
- Education degree: <%= education_degree %>
- Major: <%= education_major %>
- Graduate from: <%= education_from %>
- College attending: <%= college_attending %>
- GPA - High School: <%= gpa_school %>
- GPA-College: <%= gpa_college %>
- Languages spoken: <%= lang_speak %>
- IQ: <%= iq %>
- SAT/ACT scores: <%= satact_score %>
EDUCATION
PREGNANCY
| YEAR | OUTCOME | COMPLICATIONS |
|---|---|---|
| <%= preg_year1 %> | <%= preg_year1_outcome %> | <%= preg_year1_com %> |
| <%= preg_year2 %> | <%= preg_year2_outcome %> | <%= preg_year2_com %> |
| <%= preg_year3 %> | <%= preg_year3_outcome %> | <%= preg_year3_com %> |
| <%= preg_year4 %> | <%= preg_year4_outcome %> | <%= preg_year4_com %> |
- Have you ever been an egg donor before? <%= eggdonor_before %>
| Father | Mother | Sibling #1 | Sibling #2 | Sibling #3 | Sibling #4 | |
|---|---|---|---|---|---|---|
| Eyes Color | <%= father_eyecolor %> | <%= mother_eyecolor %> | <%= sibling1_eyecolor %> | <%= sibling2_eyecolor %> | <%= sibling3_eyecolor %> | <%= sibling4_eyecolor %> |
| Hair Color | <%= father_haircolor %> | <%= mother_haircolor %> | <%= sibling1_haircolor %> | <%= sibling2_haircolor %> | <%= sibling3_haircolor %> | <%= sibling4_haircolor %> |
| Height | <%= father_height %> | <%= mother_height %> | <%= sibling1_height %> | <%= sibling2_height %> | <%= sibling3_height %> | <%= sibling4_height %> |
| Weight | <%= father_weight %> | <%= mother_weight %> | <%= sibling1_weight %> | <%= sibling2_weight %> | <%= sibling3_weight %> | <%= sibling4_weight %> |
| Alive or deceased | <%= father_alive %> | <%= mother_alive %> | <%= sibling1_alive %> | <%= sibling2_alive %> | <%= sibling3_alive %> | <%= sibling4_alive %> |
| Current age (or age at death) | <%= father_age %> | <%= mother_age %> | <%= sibling1_age %> | <%= sibling2_age %> | <%= sibling3_age %> | <%= sibling4_age %> |
| Medical Problems (or cause of death) | <%= father_med_problem %> | <%= mother_med_problem %> | <%= sibling1_med_problem %> | <%= sibling2_med_problem %> | <%= sibling3_med_problem %> | <%= sibling4_med_problem %> |
| Paternal Grandfather | Paternal Grandmother | Maternal Grandfather | Maternal Grandmother | Child #1 | Child #2 | |
|---|---|---|---|---|---|---|
| Eyes Color | <%= p_gfather_eyecolor %> | <%= p_gmother_eyecolor %> | <%= m_gfather_eyecolor %> | <%= m_gmother_eyecolor %> | <%= child1_eyecolor %> | <%= child2_eyecolor %> |
| Hair Color | <%= p_gfather_haircolor %> | <%= p_gmother_haircolor %> | <%= m_gfather_haircolor %> | <%= m_gmother_haircolor %> | <%= child1_haircolor %> | <%= child2_haircolor %> |
| Height | <%= p_gfather_height %> | <%= p_gmother_height %> | <%= m_gfather_height %> | <%= m_gmother_height %> | <%= child1_height %> | <%= child2_height %> |
| Weight | <%= p_gfather_weight %> | <%= p_gmother_weight %> | <%= m_gfather_weight %> | <%= m_gmother_weight %> | <%= child1_weight %> | <%= child2_weight %> |
| Alive or deceased | <%= p_gfather_alive %> | <%= p_gmother_alive %> | <%= m_gfather_alive %> | <%= m_gmother_alive %> | <%= child1_alive %> | <%= child2_alive %> |
| Current age (or age at death) | <%= p_gfather_age %> | <%= p_gmother_age %> | <%= m_gfather_age %> | <%= m_gmother_age %> | <%= child1_age %> | <%= child2_age %> |
| Medical Problems (or cause of death) | <%= p_gfather_med_problem %> | <%= p_gmother_med_problem %> | <%= m_gfather_med_problem %> | <%= m_gmother_med_problem %> | <%= child1_med_problem %> | <%= child2_med_problem %> |
- Heart; including stroke, heart attack, heart disease, hardening of arteries, high blood pressure:
<%= heart_problem %> - Blood; including anemia, sickle-cell anemia, hemophilia or other bleeding problem, leukemia, immune deficiency; other blood disorders:
<%= blood_problem %> - Respiratory (lungs); including hay fever, asthma, emphysema, tuberculosis, lung cancer; pneumonia, cystic fibrosis, other lung diseases:
<%= respiratory_problem %> - Gastro-intestinal; including ulcer of stomach or duodenum, gall stones, hepatitis A (infectious), hepatitus B (serum), hemochromatosis, other liver diseases, colon cancer, ulcerative colitis, Crohn's disease, cystic fibrosis, intestinal cancer:
<%= gastro_problem %> - Metabolic/Endocrine; including diabetes mellitus, hypoglycemia, thyroid cancer, thyroid disease, goiter, adrenal dysfunction or disorder, hyperactivity:
<%= metabolic_problem %> - Urinary; including kidney disease, diseases of urinary tract (urethra, bladder, ureter), rectal disorder, polycystic kidneys, kidney stones:
<%= urinary_problem %> - Genital/Reproductive; including uterine fibroids, undescended testicle; hypospodiasis; prostate cancer;ovarian cysts; cancer of ovaries; breast cancer;, multiple miscarriages; stillbirths; childhood deaths:
<%= genital_problem %> - chorea, Gaucher's disease, Wilson's disease, Creutzfeldt-Jacob disease, Alzheimer's disease, neurofibromatosis, Tay Sachs, Canavan disease, other diseases of nervous system:
<%= neurological_problem %> - Mental Health; including schizophrenia, manic depressive, alcoholism, drug abuse/misuse/ addiction, other disorders requiring hospitalization:
<%= mental_problem %> - Muscular/Bones/Joints; including muscular dystrophy, lupus, deformity of spine, osteoporosis, dwarfism growth problem, hereditary low back disease/scoliosis, arthritis, gout:
<%= muscular_problem %> - Sight/Smell/Sound; including deafness before age 60, deformity of the ear, cataracts before age 50, blindness, color blindness, glaucoma, deviated septum, any other disorders:
<%= sight_problem %> - Skin; including acne, eczema, skin cancer, pigmentation disorders, other skin disorders or allergies:
<%= skin_problem %>
DONOR AND FAMILY MEDICAL HISTORY
GENERAL QUESTION
What interests you about being an egg donor?
<%= being_donor %>
The potential recipient will know you by your first name and/or number, and will have a picture of you. In some situations the recipient is interested in meeting their donor. How would you feel about that?
<%= potential_recipient %>
If you could share one thought of encouragement or advice with the recipient, what would that be?
<%= share_thought %>