Thanks For Your Interest In Egg DonationThank you for your interest in our Egg Donor Program. We are grateful that you want to support those who are trying to conceive. Your first step is to complete this intake questionnaire. It will help us learn more about you and your background. Some of the questions are very personal in nature, however your responses help us determine to what extent you may qualify to become a donor in our program. All the information you provide is confidential. If you do have any questions or concerns about this questionnaire, please contact us at 877-260-0352 to speak with one of our egg donor specialists. Thanks again, and let's get started!About YouFirst Name(Required) First Last Name Last Home Address(Required) Street Address City State / Province / Region ZIP / Postal Code Phone Number(Required)Email(Required) Date Of Birth(Required)MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920OccupationPlease SelectAccounting/FinanceAdvertising/Public RelationsAerospace/AviationArts/Entertainment/PublishingAutomotiveBanking/MortgageBusiness DevelopmentBusiness OpportunityClerical/AdministrativeConstruction/FacilitiesConsumer GoodsCustomer ServiceEducation/TrainingEnergy/UtilitiesEngineeringGovernment/MilitaryGreenHealthcareHospitality/TravelHuman ResourcesInstallation/MaintenanceInsuranceInternetJob Search AidsLaw Enforcement/SecurityLegalManagement/ExecutiveManufacturing/OperationsMarketingNon-Profit/VolunteerPharmaceutical/BiotechProfessional ServicesQA/Quality ControlReal EstateRestaurant/Food ServiceRetailSalesScience/ResearchSkilled LaborTechnologyTelecommunicationsTransportation/LogisticsOtherHeight (Feet)(Required)Height (Inches)(Required)Weight (Pounds)(Required)Ethnic Origin(Required)Please SelectAmerican Indian and Alaska Native alone, non-HispanicAsian alone, non-HispanicBlack or African American alone, non-HispanicHispanicMultiracial, non-HispanicNative Hawaiian and Other Pacific Islander alone, non-HispanicSome Other Race alone, non-HispanicWhite alone, non-HispanicAre you eligible to work in the United States? You must have a social security number to be eligible.(Required) Yes No Have you completed your high school diploma or a GED program? Yes No Egg Donation & Birth Control HistoryHave you ever donated eggs before? Yes No Are you adopted or are you a donor conceived child? You must know your biological family medical history including both parents, both sets of grandparents, and both sets of uncles and aunts. No Yes, I know my biological information. Yes, but I do not know by biological information. Are you willing to take self-administered injection? There are several medications that are only administered by self-injection, and there may be up to three injections daily for about a two-week timeframe. Yes No Are you willing to take birth control pills short term? Although this is not typically long term, we would require you to take oral birth control pills during the egg donor process. Yes No What is your current method of birth control?NonePill, patch, shot or vaginal ringCondoms, diaphragms, sponge or cervical capIntrauterine devices or hormonal implantsOtherDo you have a regular monthly menstrual cycle? Yes No Getting Ready For The Egg Donation ProcessDo you have flexibility at your work/school, so you can attend frequent appointments? Yes No Do you have your own transportation? Yes No Do you have a friend/family that can go to the office with you on the day of your retrieval? Yes No Do you live within 90 minutes driving distance to one of these Brown Fertility clinics? Yes No Jacksonville Orlando Winter Garden Sexual HistoryHave you had sex with a man who had sex with another man within the last 5 years? Yes No Have you injected drugs for a non-medical reason in the last 5 years, including intravenous, intramuscular and subcutaneous injection? Yes No In the past 12 months, have you had sex with anyone who would answer yes to any of these previous questions? Yes No In the past 12 months, have you had sex with a person known or suspected to have HIV infection, active hepatitis B infection or hepatitis C infection? Yes No In the past 5 years, have you been given money or drugs in exchange for having sex? Yes No In the past 12 months have you had or been treated for syphilis, chlamydia or gonorrhea? Yes No Medical History (1 Of 2)In the past 12 months, have you been exposed to known or suspected HIV, hepatitis B and/or hepatitis C infected blood through contact with an open wound, non-intact skin or mucous membrane? Yes No In the past 12 months have you had an accidental needle stick, sharp instrument injury, contact with human blood, serum or plasma in the eye, mucus membranes (lips, interior of nose) or sores? Yes No In the past 12 months, have you lived with (resided in the same dwelling) another person who has Hepatitis B or clinically active (symptomatic) Hepatitis C infection? Yes No Have you or any of your blood relatives been diagnosed with Creutzfeld-Jakob disease (CJD)? Yes No Have you been diagnosed with dementia or any degenerative or demyelinating disease of the central nervous system or other neurological disease of unknown etiology? Yes No Have you ever received growth hormone made from human pituitary glands? Yes No Medical History (2 Of 2)Have you ever received a non-synthetic dura mater (brain covering) graft? Yes No Are you suffering from hemophilia or do you have a coagulation disorder? Yes No Do you have any birth defects? Yes No Which birth defects?Do you suffer from hereditary diseases? Yes No Which diseases?Are you willing to have genetic and infectious disease testing done? Yes No Travel HistoryHave you traveled outside the continental United States within the past 6 months? Yes No Have you ever been to or had sexual contact with anyone who was born in or lived in certain countries in Africa (Cameroon, Central African Republic, Chad, Congo, Equatorial Guinea, Gabon, Niger, or Nigeria) after 1977? Yes No Have you received a blood transfusion or any medical treatment that involved blood in Cameroon, Central African Republic, Chad, Congo, Equatorial Guinea, Gabon, Niger, or Nigeria? Yes No Lifestyle HistoryDo you use nicotine (cigars, cigarettes, pouches, e-cigarettes, vape pens, etc.)? Yes No Do you use marijuana every day or almost every day? Yes No Do you take any medication? Yes No Which medications? Mental Health HistoryHave you ever suffered from depression or anxiety? Yes No Have you ever been diagnosed with schizophrenia or bipolar disorder? Yes No Are you willing to undergo a psychological evaluation? Yes No And FinallyHave you been convicted of a crime? Yes No Please explain.In the past 12 months, have you been in jail for more than 72 consecutive hours? Yes No Submission Consent(Required) I agree to Brown Fertility's use of this information.Privacy Policy Consent(Required) I agree to Brown Fertility's website privacy policy.
