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Surrogacy Agency | Los Angeles Surrogacy
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Step 1 of 38

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To become an egg donor, we need to learn some information about your personal and medical history. Your responses to these questions will help us to make sure that your health and medical history are compatible with the donation process and in particular for egg donors that it will not involve any increased risks for you. This effort will also help us to match you to an appropriate recipient.

Please provide complete and accurate information to these questions. If you do not know the answer, ask a parent or family member. Any information you provide during the donation process, will remain completely confidential. Some of the information from this questionnaire will be given to the recipient(s) as noted but all identifying information is removed.

A “yes” response will not necessarily eliminate you as a potential donor. Most people will have at least one of these conditions in themselves or a family member. The accuracy of the information you will be giving will provide information to potential families you may help to create. Instructions:

  1. Please fill in all blanks completely. Please complete all questions and write “N/A” if not applicable.
  2. Please be specific. Avoid expressions such as “natural” or “old age” (for causes of death). List any health problems as specifically as possible. If you do not know the age, put the approximate age or ask a relative to help you. List exact relationships such as “first cousin through my mother’s sister”.
  3. Please provide information on all the relatives requested. Do not write their names.
  4. If you have any questions, please call your donor coordinator.
Name as it appears on your license(Required)
MM slash DD slash YYYY
Are you a US citizen or permanent resident?(Required)
State(Required)
Home address(Required)
OK to leave message?(Required)

Donation History

Have you applied or been screened to be an egg donor before?(Required)
Donor program information
Program Name
Program Location
 
Have you donated before?(Required)
Are you currently enrolled as an egg donor in another program?(Required)
Did you consult with your family when completing your family medical history?(Required)
Signature

Personal Health History

Are you currently under a physicians care for any reason?(Required)
Have you ever had any major illnesses such as amoebic dysentery (infection of the intestine), hypertension, blood clots, pneumonia, mononucleosis, etc.?(Required)
Have you had any serious illness in the past?(Required)
Please list any surgical procedures:
Procedure name
Procedure date
 
Have you ever had any broken bones?(Required)
Which bones have you broken?
Has anyone in your family, including yourself, experienced recurring and/or chronic physical symptoms that have not been evaluated by a physician (Please include those symptoms that you may not consider serious.)?(Required)
Have you ever been seen by psychiatrist, psychologist, social worker, counselor, or any other mental health professional for any reason?(Required)
Have you ever used medications such as anti-anxiety or antidepressants to treat an emotional or psychological problem?(Required)
Anti-Anxiety and Antidepressants(Required)
Medication Name
Reason Used
Date Last Used
 
Have you been vaccinated in the last 6 months?(Required)
List all prescription medications that you have taken in the preceding 12 months
Medication
How Often
Reason
 
If N/A, leave blank
List all current over-the-counter medications (include hormones, vitamins, aspirin, antacids, laxatives, herbal & sports supplements, performance-enhancing supplements including steroids, etc.)
Medication
How Often
Reason
 
If N/A, leave blank
Have you ever taken anti-malarial drugs or had malaria?(Required)
Have you had a blood transfusion?(Required)
Have you ever been refused or denied as a blood donor?(Required)
Are you eligible to work in the United States?(Required)
Is your work schedule flexible?(Required)
Have you had radiation exposure or x-ray exposure?(Required)
Have you ever been exposed to “agent orange” or any other herbicides or chemicals (military, forestry, highway service, or elsewhere)?(Required)
Which substance(s)?(Required)
When?
Where?
 

In the preceding six months, were you exposed to the following in your job, living environment or while involved in hobbies? If yes to any of these, give dates and how often you have been exposed. Please consider carefully.

Toxic Chemicals or Substances(Required)
Sprays(Required)
Fumes/Exhaust(Required)
Radiation(Required)
Flea Powder/Sprays(Required)
Lead/Lead products(Required)
Asbestos/Asbestos products(Required)
Pesticides/Herbicides(Required)
Cleaning solutions/solvents(Required)

Caffeine usage

Daily number
Daily number
Daily number
Daily number
Do you currently smoke cigarettes?(Required)
What best describes your alcohol consumption?(Required)
What type of alcohol do you usually consume?(Required)
How many drinks do you usually consume in a week?(Required)
Have you ever used recreational or illicit drugs (cocaine, marijuana, LSD, heroin, barbiturates, narcotics, opiates, amphetamines, hallucinogens, tranquilizers, PCP, steroids, or etc.)?(Required)
Which one(s) and when did you last use them?(Required)
Drug Name
Last Used
 
Do you sleep well?(Required)
Have you had acupuncture, ear and/or body piercing or tattooing in which sterile procedures may not have been used?(Required)
Do you have any tattoos or body piercings?(Required)
Please list and describe all of your tattoos and body piercings:(Required)
Date Received
Sterile needles used?
 
Have you ever had any problems with the law (i.e. DUI, custody issues, lawsuits)?(Required)
Have you ever been incarcerated?(Required)
Sexual orientation(Required)
In the last 6 months have you had unprotected sex (intercourse without a condom) with a new partner?(Required)
Have you ever injected drugs or had a sexual partner who did so?(Required)

Contraceptive History

Current contraception used:(Required)

To your knowledge, have you or any of your sexual partners been in contact with anyone or have you been personally tested or been treated for any of the following:

HIV (AIDS)(Required)
NSU (non specific urethritis)(Required)
Syphilis(Required)
Gonorrhea(Required)
Chlamydia(Required)
Trichomonas(Required)
Venereal Warts(Required)
Herpes, Genital(Required)
Viral Hepatitis B or C(Required)
Genital Sores(Required)
Other sexually transmissible diseases(Required)

Menstrual and reproductive history: for egg donors

Are your menstrual periods regular(Required)
Days
Are you periods regular when you are not on any type of hormonal birth control such as the pill, etc.?(Required)
Days
Do you bleed or spot between periods?(Required)
Do you get menstrual cramps before, during, or after your period?(Required)
Are your cramps:(Required)
Do you use medication alleviate the pain?(Required)
Have you ever had an abnormal PAP(Required)
Are you Currently Breastfeeding?(Required)

Length of time it took you to get pregnant

If N/A, leave blank
If N/A, leave blank
Pregnancy History
Boy/Girl
Delivery Date
Delivery Type (Vaginal or C-Section)
Complications
Weeks Pregnant when Delivered
Height/Weight
 
Have you ever had a pelvic infection requiring treatment with antibiotics(Required)
Do you want children in the future?(Required)

Please note that the remaining portion of this application will be shared and viewed by recipients. Please pay attention to the fact that the Intended Parents will be viewing your responses.

Physical Characteristics

Are you adopted?(Required)
Please enter a number from 1 to 99.
Recent weight loss/gain?(Required)
Change(Required)
Do you have children of your own?(Required)
Have you been an egg donor before?(Required)
Dimples(Required)
Baldness in family(Required)
Premature graying(Required)
Have you had any periodontal or orthodontic work?(Required)
(without corrective aids)
(without corrective lenses)
Do you wear glasses or contacts or have you had laser surgery?(Required)
Are/were you(Required)

Do you have astigmatism?(Required)
(blurred vision due to an irregularity in the curvature of the cornea)
Do you have any allergies?(Required)
Are they to:(Required)
For each medication allergy, describe specific substance and reaction(s) and age first noticed(Required)
Substance
Reaction
Age
 
Please list any childhood allergies that you have outgrown(Required)

Social History and Habits

Did you have any learning disabilities or weaknesses in school?(Required)
Which languages?(Required)
Musical Talent or Instrument(Required)
Instrument
Years experience
 
Have you been out of the country in the past 6 months(Required)
(Mexico etc.)
Do you plan on traveling outside the United States within the next 6 months?(Required)

Habits

Exercise habits(Required)
Your diet is(Required)
Your diet is(Required)

Reproductive History

Child #1
Normal, Above/below average
Child #2
Normal, Above/below average
Child #3
Normal, Above/below average
Child #4
Normal, Above/below average
Family Health History
(including yourself and half siblings)
Do you have any brothers or sisters that died in infancy or childhood?(Required)
Are there any members of your family with a history of learning disabilities or autism?(Required)

Describe genetic family members according to the following characteristics. Use natural eye and hair color; fair/dark, etc. complexion. If they are deceased, please list cause of death. Please do not put “natural” as a cause of death. If unknown, write “unknown.”

Sister(s)
Eye color
Hair color
Complexion
Height
Weight
Bone Structure
Occupation
Age
Cause of death (if applicable)
 
Brother(s)
Eye color
Hair color
Complexion
Height
Weight
Bone Structure
Occupation
Age
Cause of death (if applicable)
 
Mother
Eye color
Hair color
Complexion
Height
Weight
Bone Structure
Occupation
Age
Cause of death (if applicable)
 
Father
Eye color
Hair color
Complexion
Height
Weight
Bone Structure
Occupation
Age
Cause of death (if applicable)
 
Maternal Grandmother
Eye color
Hair color
Complexion
Height
Weight
Bone Structure
Occupation
Age
Cause of death (if applicable)
 
Maternal Grandfather
Eye color
Hair color
Complexion
Height
Weight
Bone Structure
Occupation
Age
Cause of death (if applicable)
 
Paternal Grandmother
Eye color
Hair color
Complexion
Height
Weight
Bone Structure
Occupation
Age
Cause of death (if applicable)
 
Paternal Grandfather
Eye color
Hair color
Complexion
Height
Weight
Bone Structure
Occupation
Age
Cause of death (if applicable)
 

Carefully review the following list of medical problems and identify which ones you or one of your genetic relatives have or had. Please consider each condition carefully for each family member. Explain any conditions you check below, indicating which side of the family (maternal or paternal), the age at the time of onset, and any other pertinent information. If you and none of your indicated family members have a history of the specific medical condition, please indicate none.

Cancer
Breast(Required)
(which side of family, age of onset, etc.)
Colon or Intestinal(Required)
(which side of family, age of onset, etc.)
Lung(Required)
(which side of family, age of onset, etc.)
Ovarian or Uterine(Required)
(which side of family, age of onset, etc.)
Prostate or Testicular(Required)
(which side of family, age of onset, etc.)
Skin(Required)
(which side of family, age of onset, etc.)
Stomach(Required)
(which side of family, age of onset, etc.)
Thyroid(Required)
(which side of family, age of onset, etc.)
Blood (e.g. leukemia)(Required)
(which side of family, age of onset, etc.)
Heart
Stroke(Required)
(which side of family, age of onset, etc.)
Heart Attack(Required)
(which side of family, age of onset, etc.)
Congenital Heart Disease(Required)
(which side of family, age of onset, etc.)
Heart Disease or Defect(Required)
(which side of family, age of onset, etc.)
Hardening of the Arteries(Required)
(which side of family, age of onset, etc.)
High Blood Pressure(Required)
(which side of family, age of onset, etc.)
High cholesterol level(Required)
(which side of family, age of onset, etc.)
Blood
Anemia(Required)
(which side of family, age of onset, etc.)
Sickle-Cell Anemia(Required)
(which side of family, age of onset, etc.)
Factor V Leiden thrombphilia (Blood clots or strokes)(Required)
(which side of family, age of onset, etc.)
Hemophilia or other Bleeding/Clotting Disorders such as Von Willebrand’s Disease(Required)
(which side of family, age of onset, etc.)
Immune Deficiency(Required)
(which side of family, age of onset, etc.)
Leukemia(Required)
(which side of family, age of onset, etc.)
Lymphoma or Swollen Lymph Nodes(Required)
(which side of family, age of onset, etc.)
HIV(Required)
(which side of family, age of onset, etc.)
Thalassemia(Required)
(which side of family, age of onset, etc.)
Polyarteritis Nodosa(Required)
(which side of family, age of onset, etc.)
Other Blood Disorder(Required)
(which side of family, age of onset, etc.)
Respiratory
Asthma(Required)
(which side of family, age of onset, etc.)
Hay Fever(Required)
(which side of family, age of onset, etc.)
Emphysema(Required)
(which side of family, age of onset, etc.)
Tuberculosis(Required)
(which side of family, age of onset, etc.)
Pneumonia(Required)
(which side of family, age of onset, etc.)
Alpha-1 antitrypsin Disorder(Required)
(which side of family, age of onset, etc.)
Blood in Sputum(Required)
(which side of family, age of onset, etc.)
Other Lung Disease(Required)
(which side of family, age of onset, etc.)
Gastro-intestinal
Appendicitis(Required)
(which side of family, age of onset, etc.)
Ulcer of Stomach or Duodenum(Required)
(which side of family, age of onset, etc.)
Gallstones(Required)
(which side of family, age of onset, etc.)
Hepatitis A,B or C(Required)
(which side of family, age of onset, etc.)
Cirrhosis of the Liver(Required)
(which side of family, age of onset, etc.)
Other Liver Disease(Required)
(which side of family, age of onset, etc.)
Ulcerative Colitis(Required)
(which side of family, age of onset, etc.)
Crohns Disease(Required)
(which side of family, age of onset, etc.)
Pyloric Stenosis(Required)
(which side of family, age of onset, etc.)
Multiple Polyps of the Colon(Required)
(which side of family, age of onset, etc.)
Rectal Disorder(Required)
(which side of family, age of onset, etc.)
Inflammatory Bowel Disease(Required)
(which side of family, age of onset, etc.)
Any other problem of the digestive system(Required)
(which side of family, age of onset, etc.)
Metabolic/endocrine
Diabetes requiring insulin therapy(Required)
(which side of family, age of onset, etc.)
Diabetes not requiring insulin therapy(Required)
(which side of family, age of onset, etc.)
Childhood Diabetes(Required)
(which side of family, age of onset, etc.)
Thyroid disorder(Required)
(which side of family, age of onset, etc.)
Goiter(Required)
(which side of family, age of onset, etc.)
Hypoglycemia(Required)
(which side of family, age of onset, etc.)
Adrenal Dysfunction or Disorder(Required)
(which side of family, age of onset, etc.)
Phenyl Ketonuria (PKU) or inherited Metabolism Disorder(Required)
(which side of family, age of onset, etc.)
Obesity(Required)
(which side of family, age of onset, etc.)
Dwarfism(Required)
(which side of family, age of onset, etc.)
Urinary
Kidney Problems(Required)
(which side of family, age of onset, etc.)
Polycystic Kidney Disease(Required)
(which side of family, age of onset, etc.)
Other disease/ defect of urinary tract (urethra, bladder, ureter)(Required)
(which side of family, age of onset, etc.)
Genital/reproductive
Hermaphroditism/ Ambiguous Genitals(Required)
(which side of family, age of onset, etc.)
Hypospadias or undescended testicle(Required)
(which side of family, age of onset, etc.)
Uterine Fibroids(Required)
(which side of family, age of onset, etc.)
Ovarian Cysts or Ruptured(Required)
(which side of family, age of onset, etc.)
Lumps or Cysts in Breast or Discharge(Required)
(which side of family, age of onset, etc.)
Polycystic Ovarian Syndrome (PCOS)(Required)
(which side of family, age of onset, etc.)
Pelvic Inflammatory Disease (PID)(Required)
(which side of family, age of onset, etc.)
Endometriosis(Required)
(which side of family, age of onset, etc.)
Reproductive outcomes
2 or more Miscarriages(Required)
(which side of family, age of onset, etc.)
Stillborn(Required)
(which side of family, age of onset, etc.)
Premature Menopause(Required)
(which side of family, age of onset, etc.)
Death of a newborn infant(Required)
(which side of family, age of onset, etc.)
Childhood death(Required)
(which side of family, age of onset, etc.)
Birth defects(Required)
(which side of family, age of onset, etc.)
Infertility(Required)
(which side of family, age of onset, etc.)
Premature Birth(Required)
(which side of family, age of onset, etc.)
Depression(Required)
(which side of family, age of onset, etc.)
Schizophrenia(Required)
(which side of family, age of onset, etc.)
Manic Depressive or Bipolar Disorder(Required)
(which side of family, age of onset, etc.)
Other mental health disorder requiring hospitalization(Required)
(which side of family, age of onset, etc.)
Suicide Attempts(Required)
(which side of family, age of onset, etc.)
Other mental health problems that warranted counseling (please list)(Required)
(which side of family, age of onset, etc.)
Muscle/bone/joints
Muscular Dystrophy(Required)
(which side of family, age of onset, etc.)
Achondroplasia – form of dwarfism with abnormal bone growth(Required)
(which side of family, age of onset, etc.)
Other Chronic Muscle Disease(Required)
(which side of family, age of onset, etc.)
Osteogenesis imperfecta (brittle bone disease)(Required)
(which side of family, age of onset, etc.)
Loss of Muscle Coordination(Required)
(which side of family, age of onset, etc.)
Osteoporosis(Required)
(which side of family, age of onset, etc.)
Marfan Syndrome(Required)
(which side of family, age of onset, etc.)
Arthritis(Required)
(which side of family, age of onset, etc.)
Rheumatoid or Juvenile Arthritis(Required)
(which side of family, age of onset, etc.)
Spinal Muscular Atrophy(Required)
(which side of family, age of onset, etc.)
Hereditary Low Back Disorder or Deformity of Spine(Required)
(which side of family, age of onset, etc.)
Reiter’s Disease(Required)
(which side of family, age of onset, etc.)
Myasthenia Gravis(Required)
(which side of family, age of onset, etc.)
Gout(Required)
(which side of family, age of onset, etc.)
Metabolic Bone Disease (be more specific)(Required)
(which side of family, age of onset, etc.)
Lupus (systemic lupus erythematosis – SLE)(Required)
(which side of family, age of onset, etc.)
Sight/sound/smell
Deafness before age 60(Required)
(which side of family, age of onset, etc.)
Deformity of the ear(Required)
(which side of family, age of onset, etc.)
Cataracts before age 50(Required)
(which side of family, age of onset, etc.)
Blindness(Required)
(which side of family, age of onset, etc.)
Color Blindness(Required)
(which side of family, age of onset, etc.)
Severe Myopia(Required)
(which side of family, age of onset, etc.)
Glaucoma(Required)
(which side of family, age of onset, etc.)
Retinoblastoma(Required)
(which side of family, age of onset, etc.)
Retinitis Pigmentosa(Required)
(which side of family, age of onset, etc.)
Deviated Septum(Required)
(which side of family, age of onset, etc.)
Any other Sensory Disorder(Required)
(which side of family, age of onset, etc.)
Skin
Acne(Required)
(which side of family, age of onset, etc.)
Albinism(Required)
(which side of family, age of onset, etc.)
Eczema(Required)
(which side of family, age of onset, etc.)
Excessive Facial Hair (Hirsutism)(Required)
(which side of family, age of onset, etc.)
Pigmentation Disorders(Required)
(which side of family, age of onset, etc.)
Psoriasis(Required)
(which side of family, age of onset, etc.)
Neurofibromatosis(Required)
(which side of family, age of onset, etc.)
Other disorders of the skin(Required)
(which side of family, age of onset, etc.)
Infectious Skin Disease(Required)
(which side of family, age of onset, etc.)
More than 5 purple- or coffee- colored spots on skin (size of quarter or larger)(Required)
(which side of family, age of onset, etc.)
Congenital abnormalities/birth defects
Cleft Lip / Palate(Required)
(which side of family, age of onset, etc.)
Congenital Hip Problems(Required)
(which side of family, age of onset, etc.)
Club Feet(Required)
(which side of family, age of onset, etc.)
Heart Defect(Required)
(which side of family, age of onset, etc.)
Hearing Problems(Required)
(which side of family, age of onset, etc.)
Spina Bifida -Neural Tube (open spine)(Required)
(which side of family, age of onset, etc.)
Microcephaly(Required)
(which side of family, age of onset, etc.)
Holoprosencehpaly – a single-lobed brain structure and severe skull and facial defects(Required)
(which side of family, age of onset, etc.)
Chromosomal abnormalities
Down Syndrome(Required)
(which side of family, age of onset, etc.)
Other (i.e. Turner, Fragile X, Klinefelter’s etc.)(Required)
(which side of family, age of onset, etc.)
Other
Alcoholism(Required)
(which side of family, age of onset, etc.)
Drug abuse, Misuse or Addiction(Required)
(which side of family, age of onset, etc.)
Premature degeneration of any organ system(Required)
(which side of family, age of onset, etc.)
Any other condition not mentioned above(Required)
(which side of family, age of onset, etc.)

Genetic History

Ethnic origin (e.g., French, Irish) please do not just put “Caucasian”

Race: Check all that apply for your ancestors

African American
Eastern European (Ashkenazi) Jewish
Mediterranean (Greek, Italian) Hispanic
Indian (from India)
Southeast Asian (Laotian, Vietnamese, Cambodian)
French
Canadian
Cajun

Have you or anyone in your family ever been tested positive as a carrier or had any of any of the following diseases?

Blooms Syndrome(Required)
Select the applicable type(Required)
Canavan(Required)
Select the applicable type(Required)
Cystic Fibrosis(Required)
Select the applicable type(Required)
Fabry Disease(Required)
Select the applicable type(Required)
Familial Dysautonomia(Required)
Select the applicable type(Required)
Familial Mediterranean Fever(Required)
Select the applicable type(Required)
Fanconi Anemia Grp. C(Required)
Select the applicable type(Required)
Gaucher(Required)
Select the applicable type(Required)
Niemann-Pick type A(Required)
Select the applicable type(Required)
Mucolipidosis type IV(Required)
Select the applicable type(Required)
Sickle Cell(Required)
Select the applicable type(Required)
Tay-Sachs(Required)
Select the applicable type(Required)
Thalassemia(Required)
Select the applicable type(Required)
Please provide the following information about your family

Father

Mother

Sister(s)(Required)
Intellectual/Academic Achievements
Artistic Achievements
 
Brother(s)(Required)
Intellectual/Academic Achievements
Artistic Achievements
 

Donor Acknowledgement

Please confirm your acknowledgment of each item:(Required)
Full Name(Required)
Thank you for taking the time to complete this application.

I declare that all of the above information and statements made regarding myself and my family’s health history are true and correct. This Egg Donor Health History and Background form has been completed without perjury.

MM slash DD slash YYYY
This field is for validation purposes and should be left unchanged.
Los Angeles Surrogacy | 800-204-7129 | 1901 Ave of the Stars, Suite 200, Los Angeles, CA 90067 | WeChat ID: LosAngelesSurrogacy
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