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FB 1257

Personal Information
  • Age
    22
  • Body Type
    Hourglass
  • Height
    5 ft 3 in
  • Weight
    115
  • Any recent change in weight?
    No
  • Bone structure
    Small
  • Body and facial features
    Small
  • Dexterity
    Right handed
Skin & Teeth
  • Tan ability
    Medium
  • Skin condition
    Medium
  • Dimples
    Yes
  • Teeth condition
    Good
  • Orthodontic work?
    Yes
  • How old were you?
    13
Eyes, Vision and Hearing
  • Eye color
    Brown
  • Eye shape
    Round
  • Eye size
    Average
  • Eye set
    Average
  • How is your vision?
    Good
  • Do you need glasses or contact or have had corrective laser surgery?
    Yes
  • If yes, were/are you?
    Nearsighted
  • Do you have astigmatism?
    Yes
  • If yes, how old were you when it was diagnosed?
    16
  • How is your hearing?
    Excellent
Hair
  • Hair color
    Light 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
  • Sexual orientation
    Heterosexual
  • Total number of sexual partners in the last month
    1
  • Total number of sexual partners in the last 6 months
    2
  • Total number of sexual partners in the last 5 years
    3
  • Current sexual practice
    Vaginal, Oral given, Oral received
  • Past sexual practice
    Vaginal, Oral given, Oral received
  • 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
    Mixed
  • Are you adopted?
    No
  • Mother
    Philippines, Italy, Spain, Navajo (Native American)
  • Maternal grandmother
    Philippines, Italy
Race and Ethnicity
  • Maternal grandfather
    Spain, Navajo (Native American)
  • Paternal grandmother
    Norway, Sweden
  • Paternal grandfather
    Philippines, China
  • Religion
    Catholic
Menstrual
  • Age at which you had your first period
    12
  • I sometimes have bleeding after intercourse
    No
  • I sometimes have bleeding in between my normal periods
    No
  • Longest number of days of bleeding
    5
  • Shortest number of days of bleeding
    3
  • 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
    25
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)
    In the past
  • Birth Control Patches (Xulane)
    Never
  • Progesterone Injections (Depo-Provera)
    In the past
  • Progesterone Implants (Implanon, Nexplanon)
    Never
  • 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
  • Pregnancy #1 Year
    N/A
  • Pregnancy #1 Comments
    N/A
  • Pregnancy #2 Year
    N/A
  • Pregnancy #2 Comments
    N/A
Pregnancy History
  • Pregnancy #3 Year
    N/A
  • Pregnancy #3 Comments
    N/A
  • Pregnancy #4 Year
    N/A
  • Pregnancy #4 Comments
    N/A
Tattoos and Piercings
  • First time
    2017-01-03
  • Was this a Tattoo or Piercing?
    Piercing
  • Location on Body:
    Bilateral ears and bilateral nostrils
  • Sterile Needles Used?
    Yes
  • Second time
    2019-05-07
  • Was this a Tattoo or Piercing?
    Piercing
  • Location on Body:
    Bilateral ears and bilateral nostrils
  • Sterile Needles Used?
    Yes
  • Third time
    2018-07-11
  • Was this a Tattoo or Piercing?
    Piercing
  • Location on Body:
    Bilateral ears and bilateral nostrils
  • Sterile Needles Used?
    Yes
  • Fourth time
    2020-02-15
  • Was this a Tattoo or Piercing?
    Piercing
  • Location on Body:
    Bilateral ears and bilateral nostrils
  • Sterile Needles Used?
    Yes
Lifestyle
  • Athletic talents
    Volleyball
  • Interests or Hobbies
    Other
  • Interests or Hobbies (Other)
    Gym
  • Amount of exercise
    Regular
  • Type of exercise
    Other
  • Dietary restrictions
    None
  • Type of diet (Other)
    Non-vegetarian
  • Type of diet
    Other
  • Type of exercise (other)
    Cardio and weight lifting
  • Quality of diet
    Average
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
  • 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
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
  • Specific genetic mutations and variants (other)
    Donor tested negative to 288 genes
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
    None of the above
  • Psychological / Emotional problems
    I have sought counseling for emotional problems
  • 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
  • Genetic testing done?
    Yes
  • Family Birth defects / Congenital abnormalities
    None
  • Family birth defect comments
    None
  • Family Chromosome abnormalities
    None
  • Family - Specific genetic mutations and variants
    None
  • Family genetic comments
    None
  • Family - Specific genetic mutations and variants
    None
  • Family genetic comments
    None
Table
  • Family - Cancer
    None
  • Family Cancer (Other)
    None
  • Family cancer comments
    None
  • Family - Neurologic problems
    None
  • Family - Neurologic problems (other)
    None
  • Family neurologic comments
    None
  • Family - Diseases with genetic risk factors
    Diabetes, Other
  • Family - Diseases with genetic risk factors (Other)
    Father, paternal uncle, and paternal grandfather all have blue-yellow color blindness. Because blue yellow is autosomal dominant, only one mutation is needed. As the patient is not blue yellow color blind then it would seem she doesn't have the mutated gene and no risk to have a child with it.
  • Family - Problems that affect fertility
    None
Education
  • High school
    Graduated high school
  • College
    Attended but did not graduate
  • What college degrees have you earned?
    None yet
  • Trade school
    I did not attend a trade school
Education
  • How many languages do you speak
    2
  • Which languages do you speak?
    English and Spanish
  • Musical training or talents
    Other
  • Musical training or talents (other)
    Violin
  • Artistic training or talents
    Drawing
  • Current employment
    Other
  • Current employment (other)
    Full Time
Donor Info
  • Egg donation experience
    More than 1 previous egg donation
  • If you have donated before, how many times?
    6
  • Personal statement

    The idea to donate my eggs first came from a family friend who was commenting on how healthy my family was and how lucky someone would be to have a kid who had our genes. My mother proceeded to donate her eggs, but at the time I didnt think too much of it. When I was 17, my mother died in a car crash. I want to follow in so many of her steps, and donating my eggs for a family who cannot have one on their own, or they need a little bit of help, is one of those. I would like to donate my eggs not just to help the families who need it, but to know I would be making my mom proud.

Donor Info
  • I am interested in becoming a donor because:
    I think it would be a rewarding experience for me
  • Access to the office
    Far away
  • Donor Type
    Frozen Egg Donor

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