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Donor Questionnaire

Donor Information Form
1. IDENTIFYING INFORMATION
Date _____________________
Name ______________________________________________
Street Address _______________________________________
City _____________________ Province _________ Postal Code ________________
Home Phone Number ____________________ Can leave message? Yes____ No_____
Work Phone Number ____________________ Can leave message? Yes____ No_____
Cellular Phone Number___________________ Can leave message? Yes____ No_____ Email Address __________________________
Fax _____________________
Date of Birth (mm/dd/yy) _____________________
Marital Status ________________ Partner’s Name (If applicable) __________________
Number of Divorces ______
Duration of Current Relationship _____
Donating to (Name of Recipient Couple) ______________________________________
2. CHARACTERISTICS
Eye Colour __________________ Complexion (fair, medium, dark) _____________
Natural Hair Colour ____________ Hair Type (straight, curly, frizzy, etc) ____________
Eye Sight (normal, normal with correction, farsighted, nearsighted, astigmatic) ________
Height ______ Weight ______ Body Build (small, medium, large)__________________
Left/Right Handed _____________________ Ethnic Origin _____________________
Religion at Birth ___________________ Religion of Practice ____________________
3. EDUCATION AND OTHER INTERESTS
Completed High School • Yes • No
Completed Trade School • Yes • No
Completed College • Yes • No
Completed University • Yes • No
Please state degrees or diplomas acquired ______________________________________
Do you have plans to further your education? If yes, please describe. ________________________________________________________________________
When in school, what did you enjoy most? _____________________________________
What did you enjoy least? __________________________________________________
What is your current employment position? ____________________________________
How long have you been at your current position? _______________
If less than three years, what did you do before? _________________________________
What do you like most about your current job? __________________________________
________________________________________________________________________
What do you enjoy least? ___________________________________________________
________________________________________________________________________
Describe your goal(s) in life:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
What is your favourite book and why?
________________________________________________________________________
________________________________________________________________________
What is your favourite movie and why?
________________________________________________________________________
________________________________________________________________________
What are your hobbies and interests?
________________________________________________________________________
________________________________________________________________________
Describe your personality:
________________________________________________________________________
________________________________________________________________________
Please check off those characteristics that apply to you:
• Active • Artistic (visual) • Musical • Writing • Introvert
• Athletic • Artistic (theatre) • Creative • Dance • Extrovert

What do you consider to be your greatest attribute?
________________________________________________________________________
________________________________________________________________________
What is your biggest weakness?
________________________________________________________________________
________________________________________________________________________
As a child, what was your relationship with your parents like?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

What is the most useful lesson that your mother or father taught you?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Why do you want to be an egg donor?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
What message would you like to pass along to the prospective parents?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
How important is it to you to meet the prospective parents? Please check and explain if desired:
• Not at all important. I do not want to meet. Complete anonymity is important to me.
• Somewhat important. I don’t know if I want to meet at this point or not.
• Very important. I would really like to meet the couple and would not like to be an egg donor unless I meet the prospective parents.
• It really doesn’t matter to me and I would defer to the wishes of the prospective parents.
• Other. Please explain:
________________________________________________________________________
________________________________________________________________________
Please indicate the level of involvement that you would like to have in the life of any children born (please check all that apply):
• I would like to be informed that a child is born.
• I would like to receive updates and a photo every few years.
• My involvement with the child would end after I donated the eggs.
• I would defer to the wishes of the prospective parents.
• Other. Please explain:
________________________________________________________________________
________________________________________________________________________

4. MEDICAL HISTORY
Blood Type (if known) _________
Physician’s name and phone number: _________________________________________
Have you lost greater than 15 pounds of weight in the last year? If so, please explain:
________________________________________________________________________
________________________________________________________________________
Do you consider yourself to have a weight problem? _____________
Do you follow a particular food diet or have special dietary habits? If so, please specify:
________________________________________________________________________
________________________________________________________________________

List the forms and frequency of current regular vigorous exercise (swimming, running, cycling etc) and age you began:
Exercise Hours/Week Age you began

Have you ever had pelvic or uterine surgery? • Yes • No
If yes, please specify dates and type of surgery:
____________________________________________ Date _____________________
____________________________________________ Date _____________________
Have you ever had any other types of surgery? • Yes • No
If yes, please specify dates and type of surgery:
____________________________________________ Date _____________________
____________________________________________ Date _____________________
Have you been immunized against German Measles • Yes • No

Do you have or have you ever had (please check all that apply):
• Asthma • Anemia • Gall Bladder Problems
• Parasitic Infection • Appendicitis • Gonorrhea
• Pelvic Infection • Arthritis • Blood Transfusions
• Pneumonia • Bulimia/Anorexia • Breast Discharge
• Heart Disease • Poor Sense of Smell • Depression
• Breast Soreness • Rheumatic Fever • Scarlet Fever
• Cancer Specify_______ • Herpes • Syphilis
• Seizures Specify______ • Excessive Hair Growth • Chronic Bronchitis
• Chlamydia • High Blood Pressure • Diabetes
• Kidney Infection • Thyroid Problems • Ulcers
• Tuberculosis • Kidney Disease • Crohn’s/Colitis
• Ovarian Cysts • Chronic Headaches • Colour Blindness
• Loss of Balance • Vaginitis • Endometriosis
• Dizziness • Neurological Problems •
• Nongonococcal Urethritis • Epilepsy
• Polycystic Ovarian Disorder • Liver Problems
Specify __________

Other (please list): ________________________________________________________
________________________________________________________________________
________________________________________________________________________
Allergies (please list) ______________________________________________________
________________________________________________________________________
________________________________________________________________________
Have you ever received X-Rays of the pelvic area for therapy or diagnosis?
• Yes • No
If yes, please provide details: ________________________________________________
________________________________________________________________________
________________________________________________________________________

Please list all prescription medicine taken within the last year and for what condition it was prescribed.

Medication Condition

Please list any over-the-counter medication or “herbal remedies” that you take on a regular basis (i.e. Advil, Echinicea, St. John’s Wort, etc.)

_______________________________ _______________________________ _______________________________ _______________________________ _______________________________ _______________________________

Do you or have you ever used (please check all that apply):
______ Alcohol: How many glasses per week do you usually drink?
Wine _______ Beer _______ Cocktails _______

______ Cigarettes: Smoker? ________No _______Yes If yes, since what age? _______
Number of cigarettes per day _______
If non-smoker, since what age? _______

______ Recreational Drugs: ________No _______Yes
If yes, please specify_______________________

5. MENSTRUAL AND PREGNANCY HISTORY
Age at first period: _______
What was the first date of your last period? ______________________
Are your periods regular? ________
If yes, what is the usual number of days between periods? ___________
If no, how many times per year do you menstruate? _____________
What is the usual duration of your period? __________
Do you use tampons or pads? ___________________
Are cramps present before, during, or after your period? _______________________
Are cramps ____ Mild ____ Moderate ____ Severe
Do you take pain medication for cramps? _______ Specify type ____________________
Do you bleed or spot between periods? _________ Yes _________ No
How many pregnancies (including miscarriages and abortions) have you had? _________
Pregnancy Month/Year End in Abortion? End in Miscarriage? Ectopic Pregnancy? How long to conceive? Dated of Birth Current Partner Father?
1st pregnancy
2nd pregnancy
3rd Pregnancy
4th Pregnancy
5th Pregnancy

Describe the health of your children (if applicable) ______________________________ ________________________________________________________________________________________________________________________________________________
Were there any complications during or after your pregnancy? • Yes • No
If yes, please explain ______________________________________________________
________________________________________________________________________________________________________________________________________________
Is your mother still alive? • Yes • No
Did your mother have any problems with conception or pregnancy? • Yes • No
If yes, please explain ______________________________________________________
________________________________________________________________________________________________________________________________________________
Did your mother take diethystiberisol (DES) when she was pregnant with you? • Yes • No

Have you ever been an egg donor before? • Yes • No
If yes, please describe the medication used and the number of eggs retrieved.
________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________
Was a baby born? • Yes • No • Don’t Know
Was the baby/babies born healthy? • Yes • No
If no, please explain: ______________________________________________________
________________________________________________________________________________________________________________________________________________

6. CONTRACEPTIVE/SEXUAL HISTORY
What form of contraceptive do you use now or have you used in the past? Please check all that apply.

• The Pill Type_______________ • Condom • Rhythm
• IUD Type__________________ • Withdrawal • None
• Other Specify_______________ • Foams/Jellies • Diaphragm

Are you currently using contraceptives? • Yes • No
If yes, what type? ___________________________________________
For each method used in the past, please specify length of use and reason for discontinuance:

Method Length of Use Reason for Discontinuance

If you used oral contraceptives (the Pill), were your periods regular after stopping?
• Yes • No
How often do you and your partner have sexual intercourse?
________ times per week OR __________ times per month
Is intercourse painful or difficult for you? • Yes • No
Do you use lubricants for intercourse? • Yes • No
Do you regularly douche before or after intercourse? • Yes • No

7. FAMILY HISTORY
Infertility is defined as a failure to become pregnant after one year of unprotected sex. To the best of your knowledge, do you have a family history of infertility?
• Yes • No

If yes, list the family member’s relationship to you:
__________________________________________
Are you aware of any genetic conditions in your family (i.e. Cystic Fibrosis, Tay Sachs)
• Yes • No

If yes, list the family member’s relationship to you and the genetic condition:

________________________________________________________________________
Is there a history of hormonal disorders in your family? • Yes • No

If yes, what type? ____________________________________________

Please check off all of the conditions with which your mother has ever been diagnosed:

• Asthma • Anemia • Heart Disease
• Gall Bladder Problems • Arthritis • Depression
• Hepatitis • Rheumatic Fever • Thyroid Problems
• Scarlet Fever • High Blood Pressure • Colour Blindness
• Ovarian Cysts • Epilepsy • Polycystic Ovarian Disorder
• Kidney Disease • Diabetes • Tuberculosis
• Chronic Headaches • Neurological Problems • Other Specify_____________
• Seizures
Specify________________ • Cancer
Specify________________ • Liver problems
Specify________________
• Eye Diseases • Autoimmune disorders
i.e MS, Psoriasis, Crohn’s, Celiac • Blood Disorders
i.e. polycythemia vera, IGg deficiencies
• Alzheimer’s/Dementia • Huntingtons/Parkinsons/MS

Please check off all of the conditions with which your father has ever been diagnosed:

• Asthma • Hirsiutism • Heart Disease
• Gall Bladder Problems • Arthritis • Depression
• Hepatitis • Rheumatic Fever • Thyroid Problems
• Scarlet Fever • High Blood Pressure • Tuberculosis
• Poor Sense of Smell • Epilepsy • Dizziness
• Kidney Disease • Diabetes • Liver problems
• Chronic Headaches • Neurological Problems Specify________________
• Colour Blindness • Ulcers •
• Seizures
Specify________________ • Cancer
Specify________________ • Other
Specify________________
• Eye Diseases • Autoimmune disorders
i.e MS, Psoriasis, Crohn’s, Celiac • Blood Disorders
i.e. polycythemia vera, IGg deficiencies
• Alzheimer’s/Dementia • Huntingtons/Parkinsons/MS

Please list the following information about your parents:
Mother Father
Age

Eye Colour

Weight

Height

Natural Hair Colour

Health Status
(excellent, good, fair, poor)
Occupation

Do you have siblings? • Yes • No

Please fill in the following information for each sibling:
Sibling #1 Sibling #2 Sibling #3 Sibling #4 Sibling #5
Sex
Age
Eye Colour
Weight
Height
Natural Hair Colour
Health Status
Occupation
Same Mother AND Father?

8. HISTORY OF FERTILITY THERAPY/EGG DONATION
Have you ever received fertility treatment before? • Yes • No

If yes, please provide the name and phone number of your physician.
What cause of infertility was diagnosed? ______________________________________
What drugs have you taken for infertility OR to be an egg donor? Please check all that apply:
• Chlomiphene (Chlomid, Serophene) • Danazol (Danocrine)
• HMG (Pergonal) • Urofolitropin or RSH (Metrodin)
• Estrogens • GnRH (factrel)
• Progesterone • Lupron, Synarel
• Prednisone • Orgalutran
• Antibiotics • Puregon
• hCG (Profasi, Pregnyl, APL) • Gonal-F
• Bromocriptine (Parlodel) • Fertinorm
• Other ________________________

Which of the following tests have you had performed? Please indicate when and the results if known:
Test When? Results?
Basal Body Temperature

Endometrial Biopsy

Postcoital Test

Hystersalpinogram

Hormonal Assays (FSH, prolactin, estrogen)
Ultrasound

Antibodies

Laparoscopy

Mycoplasma / Chlamydia Culture
Thyroid Tests

Other – please specify

Have you ever had surgery for tubal reversal • Yes • No

If yes, specify date(s) _________________________________________
Have you ever had surgery for adhesions? • Yes • No

Have you ever had cervical conization or cautery? • Yes • No

Have you ever had any other surgery (D&C, ovarian, appendectomy, thyroid)? • Yes • No

If yes, please specify: _________________________________________
Have you ever undergone intrauterine insemination or in vitro fertilization? • Yes • No

If yes, did you use partner OR donor sperm?________________________
Is your partner seeing a doctor for evaluation of infertility? • Yes • No

If yes, please provide name and phone number of his physician
___________________________________________________________
I _________________________________ give LifeQuest permission to release any non-identifying information to the recipient couple.

Signature ________________________________________ Date__________________
LifeQuest will not release your name or any contact information.

I, _________________________________ hereby solemnly affirm that the information provided herein is true and correct. I hereby provide my authorization to LifeQuest Centre for Reproductive Medicine to contact the physician(s) listed herein for the sole and only purpose of confirming the information that I have provided.

Signature ________________________________________ Date__________________
Please mail completed form to:

Thank you for taking the time to respond to the questionnaire.

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