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	Thank you for your interest in the Egg Donor Program at the Genetics & IVF Institute. If you are between the ages of 19 to 32.5 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)

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)
Internet Health Resources
City Pages Online
Craigs List
Other

Date of Birth:

Height:

Weight:

Hair Color:

Eye Color:

Occupation:

What is your highest level of education:
(Comments)

Currently enrolled in college?:

Ethnic Background:

Are you adopted?

Smoker?:

Have you ever been convicted of a felony?:

Are you currently taking any medication?:

Name of drug and why were you prescribed this:

Have you sought counseling in the past for emotional problems?:

If yes, please describe the reason:

Have you been diagnosed currently or in the past with one of the following:

Depression:

Schizophrenia:

Obsessive-Compulsive disorder:

Mania:

Have you ever used any of the following recreational drugs, currently or in the past?

Marijuana

Heroin

Cocaine

Barbiturates

Amphetomines

If you answered yes to any, please list approximately how
often you use these drugs and when was the last time?

Any Illnesses?:

Please Describe:

Have you spent 3 or more cumulative months in the UK
from 1980 through 1996?

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?

Have you spent a cumulative total period of 5 years or more
in Europe from 1980 until the present?

Please describe details, if necessary:

Have you ever been pregnant:

Have you ever been an egg donor before?:

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