Personal Information
  • Age
    19
  • Weight
    140
  • Any recent change in weight?
    No
  • Bone structure
    Medium
  • Body and facial features
    Medium
  • Dexterity
    Right handed
Skin & Teeth
  • Tan ability
    Medium
  • Skin condition
    Oily
  • Dimples
    Yes
  • Teeth condition
    Excellent
  • Orthodontic work?
    No
  • How old were you?
    0
Eyes, Vision and Hearing
  • Eye color
    Blue
  • Eye shape
    Almond
  • Eye size
    Average
  • Eye set
    Average
  • Do you need glasses or contact or have had corrective laser surgery?
    Yes
  • Do you have astigmatism?
    No
  • How is your hearing?
    Good
Hair
  • Hair color
    Dark blonde
  • Hair texture
    Medium
  • Hair fullness
    Medium
  • Baldness
    No
  • Premature graying?
    No
Sexual History
  • Marital status
    Single
  • Living arrangement
    Living alone
  • 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
    9
  • Current sexual practice
    Vaginal, Oral given
  • 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
    Caucasian
  • Are you adopted?
    No
  • Mother
    French-Canadian
  • Maternal grandmother
    French-Canadian
Race and Ethnicity
  • Maternal grandfather
    French-Canadian
  • Paternal grandmother
    English (British)
  • Paternal grandfather
    Slovenien
  • Religion
    Catholic
Menstrual
  • Age at which you had your first period
    12
  • I sometimes have bleeding after intercourse
    Yes
  • I sometimes have bleeding in between my normal periods
    Yes
  • Longest number of days of bleeding
    4
  • Shortest number of days of bleeding
    1
  • 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)
    Never
  • Birth Control Patches (Xulane)
    In the past
  • Progesterone Injections (Depo-Provera)
    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
  • Was this a Tattoo or Piercing?
    Piercing
  • Location on Body:
    Nose
  • Location on Body:
    Nose
  • Location on Body:
    Nose
  • Was this a Tattoo or Piercing?
    Piercing
  • Location on Body:
    Nose
Lifestyle
  • Athletic talents
    Running, Dancing, Soccer, Gymnastics, Other
  • Interests or Hobbies
    Sports, Photography, Art/Crafts, Outdoors, Yoga
  • Amount of exercise
    Occasional
  • Type of exercise
    Running, Dance, Yoga, Weight lifting, Strength training
  • Type of diet
    Other
  • Quality of diet
    Average
Drugs and Alcohol
  • Alcohol use
    Current use
  • 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
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
  • 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
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?
    Yes
Other Risk Factors
  • Neurologic problems
    None
  • Diseases with genetic risk factors
    High Blood Pressure, None
  • 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
Education
  • High school
    Graduated high school
  • College
    Currently attending
  • What is/was your college major?
    Economics and Sociology, Pre-Law
  • What college degrees have you earned?
    None yet
  • Trade school
    I did not attend a trade school
Education
  • How many languages do you speak
    3
  • Which languages do you speak?
    English, French, Spanish
  • Musical training or talents
    None
  • Artistic training or talents
    Other
  • Current employment
    I work part-time outside the home
Donor Info
  • Egg donation experience
    No previous egg donations
  • Personal statement

    My mom is my best friend. She is the strongest and most incredible person I know. My mom had her first child in high school and married her high school sweetheart. She did not go to college until much later in her life, and had 3 children by the time she was 22. She raised and provided for her children at a very young age, much to the dismay of her parents, and always made ends meet and focused on her children. By 30, my mom had 5 girls. My mom is one of the most independent and generous women I know. She has raised all of her daughters with love and acceptance, but has taught each and every one of us to love, value, and respect ourselves, but to always strive to work harder and reach further. My mom has always been my greatest supporter, the loudest cheerleader at my soccer games, the best college-essay proofreader, and my favorite advice-giver. Through high school stress and drama, my mom has always been my first call. My mom is my best friend, confidant, and inspiration.

Donor Info
  • I am interested in becoming a donor because:
    I know someone with infertility and always wanted to help, I think it would be a rewarding experience for me
  • Access to the office
    Not so close
  • Donor Type
    Egg Donor