Full Name
EGG DONOR MEDICAL QUESTIONNAIRE
Address
City
State
Zip
Country
Phone # (if none, put none)
Date of Birth
Age
Height
Which location do you prefer to be interviewed/tested?
Weight
Date of Last Menstural Period
How many times have you been pregnant?
How many live children have you given birth to?
Have you ever had an abortion? If so, please briefly explain
Please describe yourself
Please Check all that apply either today or have the past
Abnormal Pap Smear
Addiction to alcohol or drugs
Arthritis
Asthma/Breathing Problems
Autoimmune
BirthControl (other than condoms)
Bleeding Problems / Blood Clots
Blood Disorders
Cancer
Cardiac Arrhythmia (rapid heart rate)
Chronic Pancreatitis
Cirrhosis of the Liver
C-Section Pregnancy/Delivery
Exposure to Tuberculosis
Extrauterine Pregnancies
Gallstones
Gastro Issues (Crohn's, Ulcerative Colitis, etc.)
GERD (acid reflux)
Gynecological Problems
Heart Murmur
Hepatitis
Heart or Vascular disease
Hernia
High Blood Pressure, Coronary Artery Disease or Circulatory conditions
HIV or AIDS
Hormone Replacements
Hypertension/ High Blood Pressure
Hysterectomy
Incontinence (Bladder/Bowel)
Kidney Disease
Metabolic Conditions. (i.e. hypothyroidism)
Miscarriage(s)
Ovarian Cysts
Psychological or Social disorders
Previous reactions to Anesthesia
Seizures or Epilepsy
Sleep Apnea
Sexually Transmitted Disease
Stroke
Thromboembolism
Type 2 Diabetes
Unusual Stress
Uterus Fibroids/Tumors
Do you have any medical condition you have been told would disqualify you from any medical procedure or surgery?
Do you have special needs that need accommodation? (dietary, sensory, handicap, etc)
Do you have any other medical condition that you are aware of that is not listed above?
If you checked or said yes to any above, please explain
Please explain any fertility issues that you are aware of? Also give a brief fertility history
Your Medical Provider
Provider Contact #
Do we have permission to contact?
Please list all previous surgeries or hospitalizations
Please list all allergies
How did you hear about us?
Chronic, Long term Steriods (past or present)
Email (if none, put none)
Natural Hair Color
Eye Color
Ethnicity
Mother's Ethnicity
Father's Ethnicity
Skin Tone
Education
Have you ever had a miscarriage, stillbirth or an eptopic pregnancy? If yes, please briefly explain
Do you smoke?
Please list your current medications and supplements (including birth control)
Do you drink?
Depression
Endocrine Disorder
Type 1 Diabetes
Abnormal Cramping
Schizophrenia
Sickle Cell/Cystic Fibrosis
Can anyone in your family mark "yes" to the above questions? Family includes Parents, Siblings, Aunts/Uncles, Grandparents, Children, etc.
Have you ever been an egg donor before?
Do you have any medical condition that you have been told would disqualify you for any type of medical procedure or surgery?
Menstrual Disorder
Donation Location (Where are you willing to travel if we cover your flight and accommodation)
Procedure(s) Requested
If yes, was the donation successful?
Have you spent 3 or more cumulative months outside of the US from 1980 through today?
Agreement: I certify that the above information is correct. I agree to allow skyMedicus and its affiliates to use the following photos of me and likeness, as well as non-identifying information from my profile to obtain prospective clients seeking Donor Egg Services. By clicking this box, I understand that this authorization will be valid from the time my information is submitted, until 48 hrs after written notice of withdrawal is received by skyMedicus (Questions call 800-670-8450). I further understand that electronic copy of this Authorization (which will be submitted upon my clicking the "Submit" button below) is just as equally valid as any original signature or document
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Click here to read the Egg Donor FAQ
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