Egg Donor Application Información personal Nombre (Primer nombre, Segundo nombre, Apellido): Fecha de nacimiento Edad Dirección Dirección Línea 2 de la dirección Ciudad Estado Código Postal Información de contacto Correo electrónico Teléfono Otros Altura Peso Eye Color Hair Color Ethnic origin Ethnic of mother Ethnic of father Highest Level of education and Major Blood Type Current living country What is your current occupation? Do you wear or have you worn eyeglasses? Have you worn braces? Where did you grow up? Marital Status Describe your personalities Why do you want to become a donor? Being a donor is a big responsibility. It requires going to several doctor's appointments, taking injections and hav-ing minor out-patient surgery. Do you feel prepared to commit to this process? Sí No Are you open to being matched with all types of families regardless of sexual preference, marital status, ethnicity or sex of the egg recipient? Sí No If they request it, are you willing to meet your intended parents? Sí No Are you open to meeting the child in the future if that is requested? Sí No Are you open to exchanging future contact information with your intended Parents(s)? Sí No Do you have any siblings? If so, tell us about each of them: Sí No Do you have any children? If so, tell us about each of them: Sí No Medical Information Any past or current medical problems (including surgeries, accidents, birth defects, depression, etc.)? If yes, please list: Sí No Do you have any known genetic disorders? If yes, please list: Sí No Have you ever been pregnant? If yes, how many times and what was the outcome? Sí No Have you ever been a donor before? If yes, did a pregnancy occur? Sí No Are you currently taking any medication (for physical or mental health)? If yes, what medications are you on and why? Sí No Are you taking any recreational drugs? If yes, what are you taking? Sí No How often do you exercise? Family Member Information Father Edad Altura Ocupación Motherr Edad Altura Ocupación Paternal grandfather Edad Altura Ocupación Maternal grandfather Edad Altura Ocupación Maternal grandmother Edad Altura Ocupación Sibling #1 Edad Altura Ocupación Sibling #2 Edad Altura Ocupación Sibling #3 Edad Altura Ocupación If you have more than 3 siblings, please give their age, height and occupation below. Family Member Information - disorders Family Member Father Mother Paternal Grandfather Paternal Grandmother Maternal Grandfather Maternal Grandmother Sibling #1 Sibling #2 Sibling #3 Edad Mental Retardation Cáncer Intellectual Disability Autism Spectrum Disorder Congenital Physical Malformation Cystic Fibrosis Lupus Hypertension (High Blood Pressure) Memory Loss / Dementia Depresión Kidney Disease Bipolar Disorder Cardiomyopathy Allergies / Hay Fever ADHD (ADD/ADHD) Anemia Birth Defects Blindness History of Blood Transfusion Canavan Disease Additional information Family Member Father Mother Paternal Grandfather Paternal Grandmother Maternal Grandfather Maternal Grandmother Sibling #1 Sibling #2 Sibling #3 Edad Mental Retardation Cáncer Intellectual Disability Autism Spectrum Disorder Congenital Physical Malformation Cystic Fibrosis Lupus Hypertension (High Blood Pressure) Memory Loss / Dementia Depresión Kidney Disease Bipolar Disorder Cardiomyopathy Allergies / Hay Fever ADHD (ADD/ADHD) Anemia Birth Defects Blindness History of Blood Transfusion Canavan Disease Additional information Family Member Father Mother Paternal Grandfather Paternal Grandmother Maternal Grandfather Maternal Grandmother Sibling #1 Sibling #2 Sibling #3 Edad Mental Retardation Cáncer Intellectual Disability Autism Spectrum Disorder Congenital Physical Malformation Cystic Fibrosis Lupus Hypertension (High Blood Pressure) Memory Loss / Dementia Depresión Kidney Disease Bipolar Disorder Cardiomyopathy Allergies / Hay Fever ADHD (ADD/ADHD) Anemia Birth Defects Blindness History of Blood Transfusion Canavan Disease Additional information If you have more than 3 familiy members with medical disorders, please specify with details below. ¿Podéis enviarnos algunas fotos vuestras? Juro o afirmo que las declaraciones anteriores y precedentes son verdaderas y correctas según mi mejor leal saber, entender y conocimiento. Fecha de firma Enviar
