FC16.5 Egg Donor Screening Questionaire

Egg Donor screening Questionnaire
Please tick () and complete ALL questions.
Have you been an egg donor If yes,

[ ] Yes [ ] No
before? where?
Are you currently in a sexual
[ ] Yes [ ] No
relationship?
If yes, duration of relationship with
partner:
Occupatio How many years did you complete in

n: high school?
Did you go to If yes, please give

college? details
How many times have you been

pregnant?
Please give details of all your pregnancies:

Livebirth-stillbirth-miscarriage- Year Details (length of pregnancy, sex, type of
termination birth etc)
Have you ever had fertility treatment? [ ] No [ ] Yes please give details below
How regular are your periods? [ ] Always regular

[ ] Usually regular (sometimes 1-3 days late or early)
[ ] Mostly regular (sometimes skip a few weeks or a month)
[ ] Not regular (often skip 1-3 months)
[ ] Completely irregular 9no pattern at all)
[ ] I have had no periods for over a year
Do you suffer with any of the [ ] Moderate period pain
following tick all that apply to [ ] Severe period pain
you) [ ] Pain with sexual intercourse0
[ ] Bleeding after sexual intercourse
Maraval Clinic: 1B Rookery Nook, Maraval, Port of Spain. TEL: 868 622 8869, 868 622 6595
FAX: 622 0153
IVF UNIT, Medical Associates Hospital: Abercromby Street, St Joseph TEL: 662 8344, 222 8341 FAX:
222 8342
Email info@TrinidadIVF.com Website www.TrinidadIVF.com Facebook
Trinidad IVF FC16.5
[ ] Bleeding at times other than your period

[ ] Vaginal discharge that is not normal
[ ] Discharge from the breast
Do you have any medical [ ] No [ ] Yes - please give details below
problems?
Have you had any surgery? [ ] No [ ] Yes - please give details below
Have you had any hospitalizations not mentioned above?
Have you had major radiation or X-ray exposure? [ ] No [ ] Yes

If yes, please give
details:
Do you smoke? [ ] No [ ] Yes
Do you have a police [ ] No [ ] Yes - please give details below

record?
Do you take any drugs or [ ] No [ ] Yes - please give details below

medications?
Name of Medication Dosage Reason Prescribed
1.
2.
3.
4.
5.
Have you sought counseling in the past for emotional

problems?
Have you ever used any of the following?

[ ] No [ ] Yes Cocaine [ ] No [ ] Yes Marijuana or weed
FAX: 622 0153
222 8342
Trinidad IVF FC16.5
[ ] No [ ] Yes Heroin [ ] No [ ] Yes Other illegal drugs
YOUR CHARACTERISTICS How would you describe your appearance and features?
Body Frame: Small Medium Large
Natural Hair Color: Lt. Brown Brown Dark Brown Black
Blonde Premature Gray Auburn Red
Hair texture (natural state): Afro Thick and Curly Thin and curly Light wave
only Straight
Other (please describe):
Eye Color: Blue Gray Green Hazel Brown Black
Skin Tone: Fair/white Light brown Medium brown Dark brown

Ebony/black
[ ] Right Handed [ ] Left Handed [ ] Ambidextrous (can use both)
Vision (without corrective lenses): Poor Fair Good Excellent
Hearing (without corrective device): Poor Fair Good

Excellent
Teeth: Poor Fair Good Excellent
Diet: Vegetarian Non-Vegetarian
Please describe your family members ethnic and general appearance

characteristics. Please take time to complete this in as much detail as you can as
this is very IMPORTANT for the clinic
Relation Eye Hair Color Heig Weig Ethnic Origin Age L/D Cause of
Color ht ht Death
Mother
Father
Maternal
Grandmothe
r
FAX: 622 0153
222 8342
Trinidad IVF FC16.5
Maternal
Grandfather
Relation Eye Hair Color Heig Weig Ethnic Origin Age L/D Cause of
Color ht ht Death
Paternal
Grandmothe
r
Paternal
Grandfather
Siblings Eye Hair Color Heig Weig Ethnic Origin Age L/D Cause of
Color ht ht Death
If you or anyone in your family has had any of the following conditions, check yes and describe
below:
Condition YES N Condition YE N
O S O
Downs syndrome Skin Disease: Eczema/
Psoriasis
Mental Retardation Mental problems
Known Chromosomal Cystic Fibrosis
Disorder
Seizure Disorder / epilepsy Hemophilia
Muscular Dystrophy Arthritis (before age 50)
Multiple Sclerosis Sickle Cell Anemia
Premature Senility(Before Early Heart Attack(before age
age 50) 50)
Deafness (before age 50) Early stroke (before age 50)
Blindness Alcoholism
Cataracts (before age 40) Asthma
Schizophrenia or Manic High Blood Pressure
Depression
Serious Birth Defects Cancer: type and location
Cleft Lip and/or Cleft Palate B-Thalassemia
FAX: 622 0153
222 8342
Trinidad IVF FC16.5
Open Spine or Water on the A-Thalassemia

Brain
Congenital Heart Problems Diabetes Mellitus
Two or More Miscarriages or Thyroid Disease
Stillborns
Polycystic Kidney Disease Kidney disease
If you answered YES to any of the above questions, please answer the following:
Specific Relation or Family Condition Age of onset

Member
If you or anyone in your family had any of the following conditions, check yes and describe
below:
YES NO YES NO
Liver Disease Lung Disease
Appendicitis Crohns Disease
Color Blindness Huntingtons Chorea
Sarcoidosis Lupus
Tuberculosis Hepatitis A, B, or C
Ulcers Colitis
Alzheimers Osteoporosis
Gout Cerebral Palsy
Dwarfism Migraines
Wilsons Disease Glaucoma
Goiter Leukemia
Emphysema Dyslexia
Skin Cancer: Hodgkins Disease
Melanoma
Kidney/ Gall Stone
If you answered YES to any of the above questions, please answer the following:
Specific Relation or Family Condition Age of

Member onset
FAX: 622 0153
222 8342
Trinidad IVF FC16.5
Have you ever donated blood or any blood products? [ ] No [ ] Yes

Have you ever had yellow jaundice, liver disease, and [ ] No [ ] Yes
hepatitis?
Have you ever had a positive test for hepatitis? [ ] No [ ] Yes
Have you ever had radiation or chemotherapy? [ ] No [ ] Yes
Have you had a major illness or surgery in the last 12 [ ] No [ ] Yes
months?
Have you ever had a blood transfusion? [ ] No [ ] Yes
Have you had an organ or tissue transplant? [ ] No [ ] Yes
Have you had a positive test for syphilis? [ ] No [ ] Yes
Have you been treated for syphilis or gonorrhea? [ ] No [ ] Yes
Have you had sex with anyone who has taken money [ ] No [ ] Yes
for sex?
Since 1977, have you taken money or drugs for sex? [ ] No [ ] Yes
Have you had sex with a male who has had sex with [ ] No [ ] Yes
another male?
What do you hope to achieve by volunteering in the egg donor program (emotionally,
financially, etc.)?
What message would you like passed on the recipient of you eggs/their offspring?
What helped you decide to become an egg donor?
FAX: 622 0153
222 8342
Trinidad IVF FC16.5
How would you describe yourself? Please include a description of your personality and temperament:
Describe your philosophy of life:
YOUR CHILDHOOD:
Describe yourself as a child (personality, health, happiness, etc.).
What was it like growing up in your family?
What religion did you belong to as a child?
What was your earliest memory as a child?
What problems did you have as a child (health, allergies, learning, social, etc.)?
WHEN I WAS A CHILD:

My favorite thing to do
was:
FAX: 622 0153
222 8342
Trinidad IVF FC16.5
My parents taught me to
value
What I loved most about my
father was:
What I loved most about my
mother was:
ADULTHOOD:
Religion: How religious are you now? Very Moderately Not at all
What religion are you currently:

Activities: How athletic are you? Very Average Not Athletic
Do you exercise? Regularly Occasionally Not at all
What types of exercise or physical activity do

you enjoy?
Do you have musical ability?
What other skills or talents do you have (painting, writing, reading, ability at games,
crossword puzzles, handicraft, etc)? Please describe in detail.
Describe any special interests you have (Girl Scout leader, fund raiser,
pet owner, volunteer activities, etc.):
What physical, artistic, intellectual, or social abilities do you have?
What have been your

achievements as an adult?
FAX: 622 0153
222 8342
Trinidad IVF FC16.5
CONSENT FORM
I, _____________________________________________________, have completed the above questions
honestly and to the best of my knowledge and ability. I understand that this information will be
used and relied on by Trinidad IVF and Fertility Centre Limited and by its patients. I have not
knowingly nor intentionally given false or misleading information. I understand that knowingly
or intentionally providing false information will not only be a cause for my disqualification as an
egg donor, but will also allow the Trinidad IVF and Fertility Centre Limited to bring lawsuit for a
recipient in order to recover damages they might have incurred.
FAMILY NAMES:
Your mothers name and
DOB:_____________________________________________________________________________
Any other names by which she is
known:_____________________________________________________________________
Current
address:_________________________________________________________________________________________
Your fathers name and
DOB:______________________________________________________________________________
Any other names by which he is
known:______________________________________________________________________
Current
address:_________________________________________________________________________________________
DATE: ________________________
SIGNATURE:______________________________________________________
PRINT
NAME____________________________________________________________________________________
WTINESS SIGNATURE:
____________________________________________________________________________ WITNESS
NAME:__________________________________________________________________________
FAX: 622 0153
222 8342
Trinidad IVF FC16.5

FC16.5 Egg Donor Screening Questionaire

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FC16.5 Egg Donor Screening Questionaire

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Egg Donor screening Questionnaire

Please tick () and complete ALL questions.

Have you been an egg donor If yes,

Occupatio How many years did you complete in

Did you go to If yes, please give

How many times have you been

Please give details of all your pregnancies:

How regular are your periods? [ ] Always regular

[ ] Bleeding at times other than your period

Have you had any hospitalizations not mentioned above?

Have you had major radiation or X-ray exposure? [ ] No [ ] Yes

Do you smoke? [ ] No [ ] Yes

Do you have a police [ ] No [ ] Yes - please give details below

Do you take any drugs or [ ] No [ ] Yes - please give details below

Have you sought counseling in the past for emotional

Have you ever used any of the following?

[ ] No [ ] Yes Heroin [ ] No [ ] Yes Other illegal drugs

Body Frame: Small Medium Large

Natural Hair Color: Lt. Brown Brown Dark Brown Black

Blonde Premature Gray Auburn Red

Other (please describe):

Eye Color: Blue Gray Green Hazel Brown Black

Skin Tone: Fair/white Light brown Medium brown Dark brown

[ ] Right Handed [ ] Left Handed [ ] Ambidextrous (can use both)

Vision (without corrective lenses): Poor Fair Good Excellent

Hearing (without corrective device): Poor Fair Good

Teeth: Poor Fair Good Excellent

Diet: Vegetarian Non-Vegetarian

Please describe your family members ethnic and general appearance

Open Spine or Water on the A-Thalassemia

Specific Relation or Family Condition Age of onset

Specific Relation or Family Condition Age of

Have you ever donated blood or any blood products? [ ] No [ ] Yes

What helped you decide to become an egg donor?

Describe your philosophy of life:

What was it like growing up in your family?

What religion did you belong to as a child?

What was your earliest memory as a child?

WHEN I WAS A CHILD:

What religion are you currently:

What types of exercise or physical activity do

What physical, artistic, intellectual, or social abilities do you have?

What have been your

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