Donorintake/Registrationform

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DONORINTAKE/REGISTRATIONFORM

CONTACTINFROMATION:

NAME:

DOB:

AGE:

DRIVER’SLICENSE#

MARITALSTATUS:

ADDRESS:

CITY/STATE: HOMEPHONE:()

ZIP:

CELLPHONE:()

EMAIL:

CURRENTEMPLOYER:

JOBTITLE:

OCCUPATION:

WORKPHONE: ()

PERSONALHEATHINFORMATION:

PRIMARYCAREPHYSICIAN: OBGYNPHYSICIAN:

DATEOFLASTPHYISICAL: DATEOFLASTPAPSMEAR:

RESULTS: RESULTS:

AREYOUONBIRTHCONTROL?

IFYES,CHECKWHICHAPPLIES

CONTRACEPTIVEINJECTION(DEPO-PROVERA)(IFYES,DATEOFLASTINJECTION )ORALPILL NUVARING CONTRACEPTIVEIMPLANT(NORPLANT) IUD

(PLEASENOTETHATIFYOUARECHOSENTOBECOMEADONORITWILLBEYOURRESPONIBILITYTOHAVEIUDREPLACED)

DOYOUHAVEREGULARPERIODS?

IFNO,INDICATEHOWMANYDAYSBETWEENPERIODS:HAVEYOUEVERBEENPREGNANT?

IFYES,#LIVEBIRTHS:

HAVEYOUEVERBEENADONORBEFORE?

#OFCYCLES:

IFYES,PLEASEINDICATECLINICINFORMATION:

(PLEASESIGNRECORDSRELEASEFORMSOWEMAYOBTAINYOURLASTCYCLE//CLINICALINFORMATION)

DRUGALLERIGES?

LATEX/FOODALLERGIES?

EMERGENCYINFORMATION:Persontocontactincaseofemergency,notlivingattheaboveaddress.NAME:

RELATIONSHIPTOYOU:ADDRESS:

CITY/STATE: ZIP:PHONE:()

BYSIGNINGBELOWIAMSTATINGTHATTHEABOVEINFORMATIONISCORRECTTOMYKNOWLEDGEANDITISMYRESPONISABILITYTOKEEPOVERLAKEREPRODUCTIVEHEALTHWITHMYCURRENTCONTACTINFORMATION.IACKNOWLEDGETHATWITHOUTCURRENTINFORMATIONIMAYNOTBECONTACTED

ANDTHEREFOREMAYNOTBECHOSENBYAPOTENTIALRECIEPENT.

DONORSIGNATURE

DATE

DatesReviewedUpdated:

ETHNICITY:Yourethnicorigin/whereyourancestorsareoriginallyfrom.Bespecific(suchasFrench,Chinese,Ashkenzi

Jewish,Scottish,AsianIndian,PersianNOTE:“White”or“Caucasian”isNOTspecificenough

Whatisyourethnicity:

Whatistheethnicityofyourmother?Yourfather?AreyouofCaucasianancestry?

Ifyes,haveyoubeentestedasacarrierofCysticFibrosis?iftested,theresults:

AreyouofFrenchCanadianancestry?

Ifyes,haveyoubeentestedforTaySachsdisease?AreyouofJewishAncestry?

Iftested,theresults:

Ifyes(infoat

BloomSyndrome?FanconiAnemia?

Nieman-Pick?

Dysautonomia?Gaucher’sdisease?

Canavan’sdisease?TaySachsdisease?

AreyouofBlackAncestry?

Results:

Ifyes,haveyoubeentestedforSickleCelldisease?

AreyouofMediterranean(GreekorItalian)ancestry?

AreyouofCaribbean,Mexican,orCentralAmericanancestry?

AreyouofMiddleEasternancestry?

AreyouofAsianancestry?

Ifyestoanyoftheabove4questions,haveyoubeentestedasacarrierofThalassemia?

Results:

PERSONALCHARACTERISTICS

HeightWeight(lbs)EyecolorHaircolor

HairtypeSkincolor

Bodytype/bonestructureReligionborninto:

Education(checkone)CompletedgradeschoolCurrentlypursuingadegree, pleaselistCompletedcollegedegrees,pleaselist

Haveyoueverbeenconvictedofafelony?

Ifyes,listallconvictions,sentences:

Completedhighschoolorequivalent

Wereyoubornwithanytypeofbirthdefectorconditionrequiringsurgeryinthefirstfiveyearsoflife?

Doyouwearglasses?

Howisyourvisionwithoutglasses?

Estimateyourvisionwithoutglasses20/Whattypeofvisionproblemsdoyouhave

Howmanyfillingsdoyouhave?

Doyouhaveanycrowns,bridges,otherextensivedentalwork?Ifyes,pleasedescribe

Doyouhaveanyhearingloss?Ifyes,pleasedescribe

Inthepastsixmonths,haveyoubeenexposedtoanyofthefollowinginyourlivingenvironmentorwhileinvolvedinhobbiesorextra-curricularactivities?

ExposureWhenHowOften

ToxicchemicalsLawn/GardenSpraysFumes/exhaust

Fleapowders/sprays

Asbestos

I.FERTILITYHISTORY:

A-1FEMALE:(MenstrualandPregnancyHistory)

Haveyoueverbeentoldyouareinfertile?Doyouusebirthcontrol?Total#ofpregnacies:

Pleaselistallpregnancies(includeallmiscarriages,abortions,tubals,etc)

Werethereanycomplicationsorproblemsduring,includinghighbloodpressure,preeclampsia,intrauterinegrowthretardation,orgestationaldiabetes?

Explain:1.

2.

3.

Didyourequireanyofthefollowingprocedures?ifyespleaseindicateintheboxwhichpregnancies:C-sectionSurgery

BloodtransfusionAntibiotics

DCOther

Explain:1.

2.

3.

Agewhenyoufirstnoticed:BreastdevelopmentyearsoldPubichairyearsoldUnderarmhair:

yearsold

Ageatfirstperiod:yearsold.

Dateofthefirstdayofyourlastperiod

Ifyourmenstrualcyclesareregular,whatistheusualnumberofdaysfromthefirstdayofoneperiodtothefirstdayofthenext

Howmanydaysdoesyourmenstrualflowlast?

Ifyes,how?

Doyouconsideryourmenstrualflowabnormal?

Doyouhaveseverecrampingorpelvicpainwithyourperiods?

Doyouhavepelvicpainbetweenperiods?(Ifitisasignificantproblem,pleasecompletepelvicpainquestionnaire)

Doyouneedmedicationtobringonaperiod?

Doyouhavepremenstrualsymptomsotherthancramps?

Doyouspotorbleedbetweenperiods?

Doyouhavepainwithintercourse?

Areyourperiodsnow,orhavetheyeverbeenirregularorunpredictable?

Ifyes:

1.When

2.Average#ofperiodsinayear

3.Shortesttimeinbetweenperiods

4.Longesttimespentwithoutmenstruating

Doyouhaveacneoroilyskin?Doyouhaveabreastdischarge?Areyoucurrentlybreastfeeding?

Doyouhaveextrabodyhair?

Ifyes,where?

Whathasbeenyourmaximumweight?When?Whathasbeenyourminimumadultweight?When?

Haveyoueverhadasuddenweightchange?

Ifyes,when?

Doyoufeelthatyouareunderweight?Doyoufeelthatyouareoverweight?Howmanymealsdoyouusuallyeatperday?

Doyoufollowaparticularfooddietorhaveanyspecialdietaryhabits?

Haveyoueverbeendiagnosedwithaneatingdisorder,suchasanorexiaorbulemia?Haveyoueverusedself-inducedvomitingtocontrolovereating?

Doyouregularlyparticipateinanyvigorousexercise?

What:

ContraceptiveHistory

Whatkindofcontraceptiveshaveyouused,ifany?

Numberofhoursaweek

Numberofmilesaweek

IUD(ParaGard®,Mirena)PillsCondomsNuvaring®

Patch(OrthoEvra®)

ContraceptiveImplants(Norplant)Injectablecontraception(Depo-Provera(,Lunelle(,etc)Other None

Pleaselistcontraceptivesthatyouhaveusedinthepast,startingwithwhatyoucurrentlyuse

Currentcontraceptive:NameFrom

Priorcontraceptives: Name From ToNameFrom ToName From To

Haveyouoryourdoctorevernotedanyproblemswithyourcontraceptiveuse?

Explain

Haveyoueverstoppedusingacontraceptivebecauseofaproblem?

Explain

Werethereanyproblemswithyourcyclesafterstoppingthecontraceptiveuse?

Explain

IfyouhaveeverusedanIUD,didyounoteanyproblems?

Ifyes,whatwerethey?

Wasitremovedbecauseofaproblem?

Explain:

Haveyouhadtubalsterilizationprocedure(tubestied)?

Ifyes,when?

Ifyes,haveyouhadatubalreversal(tubesuntied)?when?

IfyouhaveeverusedanIUD,didyounoteanyproblems?Ifyes,whatwerethey?

Wasitremovedbecauseofaproblem?

Explain:

Haveyouhadtubalsterilizationprocedure(tubestied)?Ifyes,when?Ifyes,haveyouhadatubalreversal(tubesuntied)? when?

A-3FEMALE:(Uterine,Tubal,Pelvic)

Pleasemarkif,andwhen,youhave/hadanyofthefollowingsexuallytransmitteddiseasesorpelvicinfections?

Chlamydia DateGonorrheaDate

HIV/AIDSDate

SyphilisDate

HepatitisDate

Haveyouhadyourappendixremoved?Why?Didyourmothertakeanyhormoneswhenshewaspregnantwithyou?

HaveyoueverhadaD&Cforanabortion,toendamiscarriage,followingchildbirth,orforabnormalbleeding?

Explain:

Haveyoueverhadanyofthefollowing? Ifno,skiptothenextquestion.

ProcedureDatesResults

Laparoscopy:TubalSurgery:

OtherPelvicSurgery:

AbdominalSurgery:

Haveyoueverbeennotedtohaveorbeentreatedforendometriosis?CurrentTreatment:

PriorTreatment:

Haveyouevertakenanyofthefollowingmedicationstoinduceovulationornormalizeyourcycle?(mark)ClomidSeropohene Parlodel Follistim HCG

LetrozoleProgesteroneBravelleGonal-FGNRHPrednisoneLupron Other

DatesMedicationDoseResultsComments

III.FEMALEMEDICALHISTORY:

Doyouhaveorhaveyoueverhad(circleallthatapply):

RheumaticfeverGallbladderproblemsSeizures

Neurologicalproblems

ScarletfeverHighbloodpressure

TuberculosisLiverproblems

Epilepsy

Dizziness

Appendicitis

Lossofbalance

Hepatitis

Chronicheadaches

Ulcers

Vaginitis

PelvicinfectionColitisBreastproblemsPneumonia

Heartmurmur

Kidneyinfection

Parasites

Breastdischarge

Chickenpox AnemiaThyroidproblems ArthritisOther

Comments

Ovariancysts

Cancer

Heartdisease

Breastlump

PapSmearHistory

Whenwasyourlastpapsmear?(month/year)/Result

Whenwasyourlastabnormalpapsmear?/

Notapplicable

Haveyouundergoneanyproceduresasaresultofanabnormalpapsmear?Ifyes,whatprocedure?

BreastScreeningHistory

Haveyoueverhadamammogram?Ifyes,when/Result: Normal Abnormal-Explain

Haveyoueverundergonesurgery?

DateTypeHospital

Weretherecomplications?Werethereanesthesiaproblems?Weretherebleedingproblems?

Comments:

Areyouallergictoanymedication,drugs,foods,metals,other?

Haveyoueverhadtherapywithamentalhealthprofessional?Ifyes,whenandwhy?

Haveyoueverbeenhospitalizedforpsychiatricreasons?Ifyes,whenandwhatwerethecircumstances?

Haveyoueverbeenhospitalizedforreasonsotherthanthosealreadydescribed?Ifyes,whenandforwhatreason?

Doyouregularlytakemedications?

1.Overthecounter(list)

2.Prescriptions(list)

3.Currentlytaking(list)

Doyouuseorhaveyoueverused:

1.Alcohol

#ofglassesperweekBeerCocktailsWine

2.Cigarettes,presentlyPrioruse#packsperday#ofyears

3.Illicitorrecreationaldrugs(specify)

IV.REVIEWOFSYSTEMS:

General:Head,Eyes,Ears,NoseandThroat:Respiratory:

RecentweightgainorlossDizziness

ChronicnasalcongestionShortnessofbreath

Anorexia/BulimiaLackofenergyFever/chills

HeadachesBlurredVisionRingingears

Lossofsenseofsmell

AsthmaBronchitis

Pneumonia

Bloodycough

Other

None

Hearingloss/deafness

Other

None

Tuberculosis

Other

None

Endocrine/Hormonal:Breasts:NeurologicalProblems:

ThyroidglandproblemsDischarge

clear?bloody?milky?

eakness/Lossofbalance

Rapidweightgainorloss

Lumps

Reduction

NumbnessMemoryloss

Excessivehunger/thirst

Temperatureintolerance-hotflashesorfeelingcold

DiabetesHairloss

Other

None

Gastrointestinal:

Abnormalmammogram

Augmentation/Breastimplants

Saline? Silicon?Pain CancerOther

None

Genito-Urinary:

Headaches

MigraineheadachesSeizures/EpilepsyOther

None

Skin/Extremities

Nausea/VomitingUlcers

BladderinfectionsUnexplainedrash/inflammation

Hepatitis

Bloodinyourstools

Changeinbowelhabits

Diarrhea

KidneyinfectionsVaginalinfectionsFrequenturination

Acne

SkinCancer

Burninjury

Colitis(ulcerativeorCrohn's)Constipation

IrritableBowelSyndrome

Other

None

MentalHealthProblems:

BloodintheurineLeakingurineHerpes

Other

None

Moleschanginginappearance

Excesshairgrowth

None

Other

DepressionAnxietydisorder

None

Schizophrenia

Other

Cardiovascular

HematologicMusculoskeletal:

Palpitations/Skippedbeats

Bloodclottingdisorder/Bloodclot

Unusualmuscleweakness

ChestpainHeartattackMurmers

Highbloodpressure

Rheumaticfever

Mitralvalveprolapse

Stroke

Sicklecellanemia

Easybruising

Swollenglands/lymphnodes

Bloodtransfusions(datesandreasons)

Thrombophlebitis

Decreasedenergy/stamina

RheumatoidarthritisLupusErythematosusMyastheniagravisOther

None

Needantibioticsbeforedentalprocedures?

B-1FEMALEFAMILYHISTORY:

Other

None

RelativeAlive/DeadAge

MotherFatherSisters/Brothers:

1.S/B

2.S/B

3.S/B

4.S/B

Pleasedescribetheappearanceofyourfamilymembers:

M=maternalGM=grandmotherP=paternalGF=grandfather

Comments

FAMILYMEDICALHISTORY:

Carefullyreviewthefollowinglistofmedicalproblemsandidentifyanywhicharepresentinthelistedfamilymembers.(pleasemarkonlyifthefamilymemberhas/hadthecondition)

Explain:

Doanyhereditarydiseasesorabnormalconditionsruninyourfamily(includingbreast,bowel,orovariancancer)?

V.MOTIVATIONAL

Thisinformationisusedtohelptheprospectivedonoreggrecipientsknowalittleaboutwhotheyarechoosingsopleasefilloutthissectionascompletelyaspossible.ifmorespaceisrequiredyoumayalsoanswerthefollowingquestionsinaseparateworddocument

Describeyourpersonalityandcharacter:

Whatareyourhobbies,interests,talents?

Whatareyourdislikesand/orthingsthatfrustrateyou?

Whatareyourfavoritefoods?

Whatkindofmusicdoyoulike?

Didyouplayanyinstrumentsinschoolorcurrently?

Didyouplayanysportsinschool?

Whatisyourfavoritecolor?Whatisyourfavoritemagazine?

Didyouhaveanypetsgrowingup,orcurrently?

Whatisyourfavoritebook?

Doyouconsideryourselfoutgoing?

Whatisyourfavoritemovie?

Whatisyourfavoritetvshow?

Whatwasyourfavoritesubjectinschool?

WhatwasyourhighschoolGPA?

WhatwasyourSATscores?

Whatisyourdreamjob?

DidyourFathergotocollege?Currentcareer?

DidyourMothergotocollege?Currentcareer?

Wheredoyouseeyourselfin5years?10years?

Whatisyourfavoritechildhoodmemory?

Ifyouweretobecastasaleadroleinafilmwhatwouldyourcharacterbelike?

Whatplaceshaveyoutraveled,orplacesyouwouldliketogo,andwhy?

Whatisonethingyouwouldchangeaboutyourselfandwhy?

Ifyoucouldpassonamessagetotherecipient(s)ofyourgametes,whatwoulditbe?

Whydoyouwanttobeadonor?

HowdidyouhearaboutthedonorprogramatOverlakeReproductiveHealth?

Iagreetobeananonymousdonor

AppendixI.GeneticCounseling

Oncechosenbyarecipientcouple,youwillbecontactedbyacertifiedgeneticcounselortoreviewyourfamilyhealthhistoryaspartofthedonorapplicationprocess. Thiswillbedonebyphoneorinperson,andusuallytake

30-40minutes.Ifanyissuesareidentifiedthatincreasetheriskofbirthdefectsorhealthproblemsinyouoryourchildren,youwillbeinformedandinvitedtomeetwiththegeneticcounselorforformalgeneticcounseling.

Especiallywithanonymousdonations,thiswillbetheonlyhistorygiventotherecipient(s).Therefore,priortotheconsultation,weaskthatyouobtainasmuchinformation,inasmuchdetail,aboutyourfamilyaspossible. Forthepurposesofthisconsultation,your“family”includes:yourparents,yourchildren,yourbrothersandsisters(bothhalfandwhole),yourniecesandnephews(onBOTHyourmotherandyourfather'sside),your

grandparents,yourauntsanduncles,andyourcousins.NameswillNOTbeincluded,topreserveyourconfidentiality.

Herearesomeexamplesofthetypesofthingsthatyouneedtoknowaboutyourfamilypriortoyourconsultation:

OYourethnicorigin/whereyourancestorsareoriginallyfrom(suchasFrench,Chinese,AshkenziJewish,

Scottish,AsianIndian,Persian). NOTE:“White”or“Caucasian”isNOTspecificenough

OAgeattimeofdeath(ideally,dateofbirthanddateofdeath)

OCauseofdeath(oftendeathcertificatesarehelpful,see

OBirthdefects(suchasspinabifida,heartdefects,cleftliporcleftpalate,DownSyndrome,undescended

testicle)

OBlindnessordeafness,inoneeyeorboth,ageofdiagnosis,gettingworseornot

OMentalretardation,specificcauseifknown,howdiagnosed,leveloffunctionODifficultyconceiving,miscarriages,stillbirths,childrendyingbeforeagefiveOHighbloodpressure,highcholesterol,whethermedicationisneededornotOStrokes,heartattacks,andtheagesatwhichtheseoccurred

OKnowngeneticconditionsrunninginyourfamily(suchassicklecell,cysticfibrosis,NF,Huntington's

Disease)

OChronichealthconditions(suchasasthma,hepatitis,Chron'sdisease,irritablebowelsyndrome,multiple

sclerosis[MS])

ODiabetes,whethercontrolledbydiet,pills,orinsulinshots,andageatdiagnosis

OBreastcancer,ageatdiagnosis,whetheronebreastorboth,howtreated,anyrecurrence

OOvariancancer,ageatdiagnosis,howtreated,anyrecurrence

OColoncancer,ageatdiagnosis,anypolyps,howtreated,anyrecurrence

OOthercancer,ageatdiagnosis,howtreated

OMentalillness,specificdiagnosis,whethermedicationstaken

OAlcoholism,drugabuse,whetherandhowtreated

Ifyouhavealreadyhadanytypeofgenetictestingdone(suchasbeingscreenedforsicklecelltraitorTay-Sachsdisease),pleaseobtaincopiesofthosetestresultsforourfile.Ifyouneedhelpwiththis,pleasetelltheovumdonorprogramcoordinator. Additionally,pleaseobtainandsubmitallrelevantmedicalrecords(i.e.fromyourOB-Gynoffice).Wewillneedtoreviewthesewithyouatyourfirstappointment.

Pleasecompleteasmuchofthefamilyhistoryportionasyoucanpriortoyourinitialinterviewappointment.Thiswillbeneededwhenyouareselectedbyarecipientcoupleandproceedintothegeneticscreeningportionoftheapplicationprocess.