EA 1308

Personal Information

• Age
  22
• Body Type
  Apple
• Height
  5 ft 8 in
• Weight
  185
• Any recent change in weight?
  No
• Bone structure
  Medium
• Body and facial features
  Medium
• Dexterity
  Right handed

Skin & Teeth

• Tan ability
  Slight
• Skin condition
  Medium
• Dimples
  No
• Teeth condition
  Good
• Orthodontic work?
  Yes
• How old were you?
  19

Eyes, Vision and Hearing

• Eye color
  Brown
• Eye shape
  Almond
• Eye size
  Average
• 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?
  Farsighted
• Do you have astigmatism?
  No
• How is your hearing?
  Good

Hair

• Hair color
  Medium brown
• Hair texture
  Medium
• Hair fullness
  Thick
• Baldness
  No
• Premature graying?
  No

Sexual History

• Marital status
  Single
• Living arrangement
  Living together with a sexual partner
• 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
  15
• Current sexual practice
  Vaginal, Oral given
• 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
• Mother
  Dutch
• Maternal grandmother
  Dutch

Race and Ethnicity

• Maternal grandfather
  Dutch
• Paternal grandmother
  German
• Paternal grandfather
  Dutch
• Religion
  N/A

Menstrual

• Age at which you had your first period
  13
• I sometimes have bleeding after intercourse
  No
• I sometimes have bleeding in between my normal periods
  No
• Longest number of days of bleeding
  10
• 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
  20

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)
  Currently
• Intrauterine Device (IUD) Paragard, Mirena, Kyleena, Liletta, Skyla
  Never
• Barrier contraceptives (Condoms, Diaphragms, Cervical caps)
  Never
• Sterilization (tubal ligation, Essure tubal plugs)
  Never

Pregnancy History

• Tell us about your pregnancy history
  I have never been pregnant and have never tried to become pregnant

Tattoos and Piercings

• First time
  2016-08-08
• Was this a Tattoo or Piercing?
  Piercing
• Location on Body:
  Ear
• Location on Body:
  Ear
• Location on Body:
  Ear
• Was this a Tattoo or Piercing?
  Piercing
• Location on Body:
  Ear

Lifestyle

• Athletic talents
  None
• Interests or Hobbies
  Outdoors, Music, Cuisine, Pets, Reading, Acting, Baking / Cooking
• Amount of exercise
  Occasional
• Type of exercise
  Other
• Type of diet
  Any
• Quality of diet
  Average
• Type of exercise (other)
  moving heavy objects, constantly on my feet

Drugs and Alcohol

• Alcohol use
  Tried at least once
• Tobacco use
  Tried at least once
• Heroin or opiates
  Never
• Cocaine, crack
  Never
• Crystal meth
  Never
• LSD / Acid
  Never
• PCP / Angel Dust
  Never
• Other illegal drugs not listed above
  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

CJD - Creutzfeldt–Jakob disease

• Has one or more blood relatives been diagnosed with CJD?
  No

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

Education

• High school
  Attended but did not graduate
• College
  Attended but did not graduate
• What college degrees have you earned?
  None yet
• Trade school
  I graduated from a trade school
• Type of trade school
  Nursing assistant

Education

• How many languages do you speak
  1
• Which languages do you speak?
  English
• Musical training or talents
  Singing, Instrument
• Artistic training or talents
  None
• Current employment
  I work full-time outside the home

Donor Info

• Egg donation experience
  No previous egg donations
• If you have donated before, how many times?
  0
• Personal statement

  I have 11 siblings, only 1 of which is adopted, high fertility runs in the family I have a strong immune system, I have never had an std/sti

Donor Info

• Access to the office
  Far away
• Donor Type
  Egg Donor