Thank you for your interest in the Egg Donor Program at the Genetics & IVF Institute.

If you are between the ages of 19 to 31 and would like to see if you are eligible
to become a donor in our program, please complete the questionnaire below.

First Name:
Last Name:
Address:
Suite:
City:
State/Zip:
Country:
E-mail:
Phone:
Do you live within 2 hours of our main GIVF office located at 3015 Williams Drive Fairfax, VA 22031? (If you answered no, you are not eligible to participate)	Yes No
Date of Birth:
Height:	ft  in
Weight:	lbs
Hair Color:
Eye Color:
How did you FIRST hear about our program? :
If Internet please specify how you were FIRST referred to us:	Genetics & IVF Institute (www.givf.com) FaceBook Internet Health Resources City Pages Online Craigs List Other
Occupation:
What is your highest level of education: (Comments)	Graduate School College Some College Vocational Certification High School
Currently enrolled in college?	Yes No
Ethnic Background:
Are you adopted?	Yes No
If you answered yes, do you have medical history available to you for your biological relatives including parents, sibllings, aunts/uncles and grandparents?
Smoker?	Yes No
Have you ever been convicted of a felony?	Yes No
If you answered yes, please provide specific details:
Are you currently taking any medication?	Yes No
Name of drug and why were you prescribed this:
Have you sought counseling in the past for emotional problems?	Yes No
If yes, please describe the reason:
Have you been diagnosed currently or in the past with one of the following:
Depression: Yes No Schizophrenia: Yes No Obsessive-Compulsive disorder: Yes No Mania: Yes No
Have you ever used any of the following recreational drugs, currently or in the past?
Marijuana: Yes No Heroin: Yes No Cocaine: Yes No Barbiturates: Yes No Amphetomines: Yes No
If you answered yes to any, please list approximately how often you use these drugs and when was the last time?
Any Illnesses?	Yes No
Please Describe:
Have you spent 3 or more cumulative months in the UK from 1980 through 1996?	Yes No
Have you lived for 6 months or more at U.S. military bases in Northern Europe (Germany, UK, Belgium Netherlands) from 1980 through 1990 or elsewhere in Europe (Greece, Turkey, Spain, Portugal, and Italy) from 1980 through 1996?	Yes No
Have you spent a cumulative total period of 5 years or more in Europe from 1980 until the present?	Yes No
Please describe details, if necessary:
Have you ever been pregnant:	Yes No
Have you ever been an egg donor before?	Yes No
If yes, how many donation cycles have you completed?