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Member of IntegraMed™ Network Infertility, IVF Treatment Clinics

Egg Donor Qualification Survey

If you wish to pursue this rewarding oportunity which may help a couple fulfill their dream of having a family, please fill out our Egg Donor Qualification Survey below.

Basic requirements for egg donation initial eligibility include but are not limited to:

• Ability to self-administer daily injections for up to 5 weeks
• Ability to stop using hormonal birth control
• Have flexibility in work hours
• Ability to come to our office for frequent/daily monitoring

If you feel you will be able to meet these basic requirements, please complete the following survey. All questions must be answered in order to be reviewed.

First Name:
Last Name:
SS#:	###-##-####
Address:
Address 2:
City:
State:
Zip Code:
Home Phone:
Work Phone:
Cell Phone:
D.O.B.:	mm/dd/yy
Email:
What is your height?	ft. in.
What is your weight?	lbs
Are you in a relationship?	Yes No
What is your marital status?	Single Married Divorced Separated
What is your ethnic background/nationality?:

What form of birth control do you use?:
Do you have monthly periods?: Yes No
When was the first day of your last period?: mm/dd/yy
Do you have both ovaries?: Yes No
Have you ever been pregnant?: Yes No
If so, please list the number of times you've had each:
Fullterm Preterm
Miscarriages Abortions

Do you have a history of infertility and/or treatment?:
Yes No
If so, please describe:


Please list all current medications including vitamins and herbs:


Do you have a history of sexually transmitted infections?:
Yes No
If so, please describe:


Do you have a history of endometriosis?: Yes No
Do you smoke?: Yes No
If so, how much per week?:
Do you drink alcohol?: Yes No
If so, how many drinks per week?:
Do you use recreational drugs?: Yes No

Have you had a tattoo done within the last year?: Yes No
If so, what was the date and name of the establishment where it was done?:
Name, mm/dd/yy
Have you had any piercings done within the last year?: Yes No
If so, what was the date and name of the establishment where it was done?:
Name, mm/dd/yy
Do you have a history of any medical illness?: Yes No
If so, please list them:


Have you ever had surgery?: Yes No
If so, please list what type and when:
mm/dd/yy

Do you have health insurance?: Yes No
If so, please list your provider?:

Why do you want to be an egg donor?:


How did you hear about our program?:
Radio Television Newspaper
Friend Other