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KB 1855

Personal Information
  • Age
    33
  • Body Type
    Hourglass
  • Height
    5 ft
  • Weight
    116
  • Any recent change in weight?
    No
  • Bone structure
    Medium
  • Body and facial features
    Medium
  • Dexterity
    Right handed
Skin & Teeth
  • Tan ability
    Easy
  • Skin condition
    Combination
  • Dimples
    No
  • Teeth condition
    Good
  • Orthodontic work?
    No
Eyes, Vision and Hearing
  • Eye color
    Brown
  • Eye shape
    Almond
  • Eye size
    Small
  • Eye set
    Average
  • How is your vision?
    Fair
  • Do you need glasses or contact or have had corrective laser surgery?
    Yes
  • If yes, were/are you?
    Nearsighted
  • Do you have astigmatism?
    Yes
  • How is your hearing?
    Good
Hair
  • Hair color
    Dark brown
  • Hair texture
    Medium
  • Hair fullness
    Thick
  • Baldness
    No
  • Premature graying?
    No
Sexual History
  • Marital status
    Married
  • Living arrangement
    Living together with a sexual partner
  • Sexual orientation
    Heterosexual
  • Total number of sexual partners in the last month
    1
  • Total number of sexual partners in the last 6 months
    1
  • Total number of sexual partners in the last 5 years
    1
  • Current sexual practice
    Vaginal
  • Past sexual practice
    Vaginal, Oral given
  • Have you had sexual contact with a person who has injected drugs for a non-medical reason? (includes intravenous, intramuscular or subcutaneous injections)
    No
  • Have you had sexual contact with a person who has hemophilia or another blood clotting disorder who may have received human derived blood clotting factors?
    No
Sexual History
  • Have you engaged in sexual contact in exchange for money or drugs?
    No
  • Have you engaged in sexual contact with a person who has had sex in exchange for money or drugs?
    No
  • Have you had sexual contact with any person known or suspected to have infection with HIV (AIDS), a positive HIV test, Hepatitis B infection, Hepatitis C infection, Zika Virus, or any other sexually transmitted infection?
    No
  • In the last year, have you had vaginal intercourse without the use of a condom?
    No
  • Have you had sexual contact with a man who is homosexual or bisexual?
    No
  • Have you had sexual contact with an individual who was born in or lived in any of the following countries since 1977: Cameroon, Central African Republic, Chad, Congo, Equatorial Guinea, Gabon, Niger or Nigeria?
    No
Race and Ethnicity
  • Race
    Caucasian
  • Are you adopted?
    No
  • Ethnicity
    Filipino
  • Mother
    Filipino
  • Maternal grandmother
    Filipino
Race and Ethnicity
  • Maternal grandfather
    Filipino
  • Paternal grandmother
    Filipino
  • Paternal grandfather
    Filipino
  • Religion
    n/a
Menstrual
  • Age at which you had your first period
    9
  • I sometimes have bleeding after intercourse
    No
  • I sometimes have bleeding in between my normal periods
    No
  • Longest number of days of bleeding
    6
  • Shortest number of days of bleeding
    4
  • Longest time from the start of one period to the start of the next
    32
  • Shortest time from the start of one period to the start of the next
    29
Gynecologist visits
  • Have you ever been told you might have trouble having children?
    No
  • Have you ever had a pelvic exam?
    Yes
  • Have you ever had an abnormal PAP smear?
    No
Use of birth control
  • Oral Contraceptives (birth control pills)
    Never
  • Birth Control Patches (Xulane)
    Never
  • Progesterone Injections (Depo-Provera)
    Never
  • Progesterone Implants (Implanon, Nexplanon)
    Never
  • Intrauterine Device (IUD) Paragard, Mirena, Kyleena, Liletta, Skyla
    Never
  • Barrier contraceptives (Condoms, Diaphragms, Cervical caps)
    Currently
  • Sterilization (tubal ligation, Essure tubal plugs)
    Never
Pregnancy History
  • Tell us about your pregnancy history
    I have been pregnant before without really trying
  • Pregnancy #1 Year
    2009
  • Pregnancy #1 Outcome
    Delivery
  • Pregnancy #1 Comments
    No
  • Pregnancy #2 Year
    2014
Pregnancy History
  • Pregnancy #3 Year
    2016
  • Pregnancy #3 Outcome
    Delivery
  • Pregnancy #3 Comments
    No
Tattoos and Piercings
  • Was this a Tattoo or Piercing?
    Piercing
  • Location on Body:
    Ear
  • Sterile Needles Used?
    Yes
  • Was this a Tattoo or Piercing?
    Piercing
  • Location on Body:
    Ear
  • Sterile Needles Used?
    Yes
  • Was this a Tattoo or Piercing?
    Piercing
  • Location on Body:
    Ear
  • Sterile Needles Used?
    Yes
  • Was this a Tattoo or Piercing?
    Piercing
  • Location on Body:
    Ear
  • Sterile Needles Used?
    Yes
Lifestyle
  • Athletic talents
    None
  • Interests or Hobbies
    Outdoors, Yoga, Music, Working out, Baking / Cooking
  • Amount of exercise
    Regular
  • Type of exercise
    Yoga, Weight lifting, Strength training, HIIT (High Intensity Interval Training)
  • Quality of diet
    Good
  • Type of diet
    Paleo
Drugs and Alcohol
  • Alcohol use
    Tried at least once
  • Tobacco use
    Never
  • Heroin or opiates
    Never
  • Cocaine, crack
    Never
  • Crystal meth
    Never
  • LSD / Acid
    Never
  • PCP / Angel Dust
    Never
Legal history
  • I have been in trouble with the law
    No
  • I have been arrested before, but not convicted.
    No
  • I have been convicted of a crime.
    No
  • I have spent at least one hour in jail or prison.
    No
  • I have spent more than 72 consecutive hours in prison in the last year.
    No
Medical History
  • Have you injected drugs for a non-medical reason in the last 5 years?
    No
  • Do you have hemophilia and/or received human-derived clotting factor concentrates in the last 5 years?
    No
  • Have you in the last 12 months lived in the same dwelling with another person with hepatitis B infection or hepatitis C infection?
    No
  • Have you been exposed in the preceding 12 months to known or suspected HIV (AIDS), Hepatitis B, and/or Hepatitis C infected blood through a needle stick or through contact with an open wound, non-intact skin, or mucous membrane?
    No
  • Have you ever been diagnosed with any form of hepatitis?
    No
  • Have you been in juvenile detention, lock up, jail or prison in the last 12 months?
    No
  • In the last 12 months, have you gotten a new tattoo, ear piercing or body piercing, or had acupuncture treatment in which NON STERILE instruments may have been used?
    No
  • In the last 8 weeks, did you receive a smallpox vaccination (vaccinia virus)?
    No
  • In the last 12 months, have you had any contact with someone who received a smallpox vaccination or who was diagnosed with smallpox?
    No
  • Have you ever been diagnosed with smallpox?
    No
Defects
  • Birth defects / Congenital abnormalities
    None
  • Chromosome abnormalities
    None
  • Specific genetic mutations and variants
    None
  • Cancer
    None
  • Cancer (Other)
    cancer-other
CJD - Creutzfeldt–Jakob disease
  • Has one or more blood relatives been diagnosed with CJD?
    No
  • Have you ever received injections of human pituitary-derived growth hormone?
    No
  • Have you ever received a dura mater transplant?
    No
  • Have you ever been diagnosed with dementia or any degenerative or demyelinating disease of the central nervous system (CNS) or other neurological disease of unknown etiology?
    No
Medical History
  • In the last 12 months, were you diagnosed with or treated for West Nile Virus?
    No
  • In the last 12 months, were you diagnosed with or treated for Syphilis?
    No
  • In the last 12 months, were you diagnosed with or treated for Chlamydia or gonorrhea infection?
    No
  • Have you ever received a blood transfusion?
    No
  • Have you ever been turned down to be a blood donor?
    No
  • Have you ever received a transplant of any tissue, cells or fluids from a non-human, animal source?
    No
  • Have you ever had intimate contact with a recipient of a transplant of any tissue, cells or fluids from a non-human, animal source?
    No
  • Were you born in or did you live in any of the following countries since 1977?
    No
  • Did you have a blood transfusion or have any medical treatment involving blood in any of the following countries since 1977?
    No
  • Have you been vaccinated in the last 6 months?
    No
Other Risk Factors
  • Neurologic problems
    None
  • Diseases with genetic risk factors
    None
  • Infectious diseases
    infectious-diseases
  • Problems that affect fertility
    None
CJD - Creutzfeldt–Jakob disease
  • Have you ever been diagnosed with vCJD or any other form of CJD?
    No
  • Have you received any transfusion of blood or blood components in the U.K. or France between 1980 to the present?
    No
  • Have you lived cumulatively for 5 years or more in Europe from 1980 until the Present?
    No
  • Are you a current or former U.S. military member, civilian military employee, or dependent of a military member or civilian employee who resided at U.S. military bases in
    No
  • Have you spent three months or more cumulatively in the U.K. from the beginning of 1980 through the end of 1996?
    No
Family Medical
  • Family Birth defects / Congenital abnormalities
    None
  • Family Chromosome abnormalities
    None
  • Family - Specific genetic mutations and variants
    None
Table
  • Family - Cancer
    None
  • Family - Neurologic problems
    None
  • Family - Diseases with genetic risk factors
    High Blood Pressure
  • Family disease comments
    Mother has high blood pressure
  • Family - Problems that affect fertility
    None
Education
  • High school
    Graduated high school
  • College
    Attended but did not graduate
Education
  • How many languages do you speak
    1
  • Which languages do you speak?
    English
  • Musical training or talents
    Singing
  • Artistic training or talents
    None
  • Current employment
    I work full-time outside the home
Donor Info
  • Egg donation experience
    No previous egg donations
Donor Info
  • I am interested in becoming a donor because:
    I know someone with infertility and always wanted to help
  • Access to the office
    Local
  • Donor Type
    Known Donors

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1-630-357-6540

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