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IT 1186

Personal Information
  • Age
    20
  • Height
    5 ft 6 in
  • Weight
    125
  • Any recent change in weight?
    No
  • Bone structure
    Small
  • Body and facial features
    Medium
  • Dexterity
    Ambidextrous
Skin & Teeth
  • Skin condition
    Medium
  • Dimples
    Yes
  • Teeth condition
    Excellent
  • 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?
    No
  • Do you have astigmatism?
    No
  • How is your hearing?
    Good
Hair
  • Hair color
    Medium brown
  • Hair texture
    Fine
  • Hair fullness
    Medium
  • Baldness
    No
  • Premature graying?
    No
Sexual History
  • Marital status
    Single
  • 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
    2
  • Current sexual practice
    Vaginal
  • Past sexual practice
    Vaginal
  • 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
    American
  • Maternal grandmother
    American
Race and Ethnicity
  • Maternal grandfather
    American
  • Paternal grandmother
    American
  • Paternal grandfather
    American
  • Religion
    Christian
Menstrual
  • Age at which you had your first period
    14
  • 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
    3
  • Longest time from the start of one period to the start of the next
    35
  • Shortest time from the start of one period to the start of the next
    28
Gynecologist visits
  • Have you ever been told you might have trouble having children?
    No
  • Have you ever had a pelvic exam?
    No
  • 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)
    Never
  • Progesterone Implants (Implanon, Nexplanon)
    Never
  • Intrauterine Device (IUD) Paragard, Mirena, Kyleena, Liletta, Skyla
    Never
  • Barrier contraceptives (Condoms, Diaphragms, Cervical caps)
    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
Tattoos and Piercings
  • Was this a Tattoo or Piercing?
    Piercing
  • Location on Body:
    ears
  • Sterile Needles Used?
    Yes
  • Was this a Tattoo or Piercing?
    Piercing
  • Location on Body:
    ears
  • Sterile Needles Used?
    Yes
  • Was this a Tattoo or Piercing?
    Piercing
  • Location on Body:
    ears
  • Sterile Needles Used?
    Yes
  • Was this a Tattoo or Piercing?
    Piercing
  • Location on Body:
    ears
  • Sterile Needles Used?
    Yes
Lifestyle
  • Athletic talents
    Basketball, Other
  • Athletic talents (Other)
    Softball, Tennis
  • Interests or Hobbies
    Other
  • Interests or Hobbies (Other)
    writing, reading, gardening, cooking
  • Amount of exercise
    Regular
  • Type of exercise
    Other
  • Type of diet
    Other
  • Quality of diet
    Average
  • Type of exercise (other)
    cardiac
Drugs and Alcohol
  • Alcohol use
    Never
  • 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
  • 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
  • Psychological / Emotional problems
    I have sought counseling for emotional problems, I have been seen or treated by a psychologist or psychiatrist, I have used medications such as anti-anxiety or antidepressants to treat an emotional or psychological problem
Family Medical
  • Family Birth defects / Congenital abnormalities
    None
  • Family Chromosome abnormalities
    None
  • Family - Specific genetic mutations and variants
    None
  • Family genetic comments
    None
  • Family - Specific genetic mutations and variants
    None
  • Family - Cancer
    None
  • Family Cancer (Other)
    None
  • Family genetic comments
    None
Family Medical
  • Family cancer comments
    None
  • Family - Neurologic problems
    None
  • Family - Diseases with genetic risk factors
    None
  • Family disease comments
    None
  • Family - Diseases with genetic risk factors
    None
  • Family disease comments
    None
  • Family - Problems that affect fertility
    None
  • Family fertility comments
    None
Education
  • High school
    Graduated high school
  • What is/was your college major?
    Forensic Psycology
Education
  • How many languages do you speak
    1
  • Which languages do you speak?
    English
  • Musical training or talents
    Other
  • Musical training or talents (other)
    Saxophone and Bass Guitar
  • Artistic training or talents
    Other
  • Artistic training or talents (other)
    Dancing and Painting
  • Current employment
    Other
Donor Info
  • Egg donation experience
    No previous egg donations
  • Personal statement

    When I am around others, they say to never stop smiling. I always try to have a good expression and work through many situations in a fair matter. I am the type of person that wants to give to others constantly. I am a huge family person and love being around friendly, outgoing people.

Donor Info
  • I am interested in becoming a donor because:
    I think it would be a rewarding experience for me, I think the process is fascinating and wanted to be involved
  • Access to the office
    Not so close
  • Donor Type
    Egg Donor

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