Survey Results for:
2 How did you find us?
Friend or Family
3 Do you currently reside in the
United States?
Yes
4 Date of Birth
5 Age
6 Is your BMI (body mass index)
over 30?
7 Have you smoked cigarettes
and/or used tobacco in the past
year?
8 Have you used anti-depressants
or anti-anxiety medications in the
past year?
9 Have you used any illegal drugs
in the past year?
10 Does any family member have a
history of heart attack under age
55?
11 Does more than one family
member have Lupus or the same
type of cancer (i.e. breast cancer,
prostate cancer, colon cancer, etc.)
excluding lung cancer or
leukemia?
12 Did you fail to complete high
school or obtain a GED?
13 Are you adopted and unable to
provide a full family medical
health history?
14 Are you currently using any of
1985-2-23
27
No
No
No
No
No
No
No
No
No
the following for birth control:
Depo Shot, IUD, Seasonique or
Seasonale?
15 Do you have irregular periods? No
16 Are you currently pregnant?
No
Demographic
17 First Name
25 State
28 What type of families are you
open to donating to:
29 My Requested Fee is (US
Dollars):
30 Race
31 Religion
32 Place of Birth
33 Height (inches)
34 Weight (lbs)
35 BMI
36 Eye Color
37 Do you wear corrective lenses?
38 Vision Detail
39 Natural Hair Color
40 Current Hair color if different
from natural
41 Blood Type
42 Skin Tone
43 Are you Predominantly:
44 Distinguising Features?
45 Are you adopted?
46 If adopted, do you have access
to your birth family's health
history?
Tara
Utah
Heterosexual Couples
Heterosexual Singles
Homosexual Male Couples
Homosexual Single Men
Homosexual Female Couples
Homosexual Single Female
I am open to all types of families
$8,000 (recommended for 1st time donors)
caucasian
none
Weaverville California
5"1'
110
20.8 (normal)
Blue
No
I have 20/20 vision
blonde
light brown
A+
olive
Right Handed
dimples, oval shaped face, high cheek bones
No
Yes
Family Background
47 Mother's Ethnic Ancestry
caucasian
(French, English, German, etc.)
48 Mother's Height (inches)
5"5'
49 Mother's Weight
200
50 Mother's Eye Color
light brown
51 Mother's Hair Color
brown
52 Father's Ethnic Ancestry
Caucasian
(French, English, German, etc)
53 Father's Height (inches)
5"11'
54 Father's Weight
170
55 Father's Eye Color
green
56 Father's Hair Color
blonde
57 Maternal Grandmother's Ethnic
Ancestry (French, English,
caucasian
German, etc)
58 Maternal Grandmother's
5"5'
Height (inches)
59 Maternal Grandmother's
160
Weight
60 Maternal Grandmother's Eye
light brown
Color
61 Maternal Grandmother's Hair
light brown
Color
62 Maternal Grandfather's Ethnic
Ancestry (French, English,
Caucasian
German, etc.)
63 Maternal Grandfather's Height
6"
(inches)
64 Maternal Grandfather's Weight 170
65 Maternal Grandfather's Eye
blue
Color
66 Maternal Grandfather's Hair
blonde
Color
67 Paternal Grandmother's Ethnic
Ancestry (French, English,
caucasian
German, etc.)
68 Paternal Grandmother's Height 5"5'
(inches)
69 Paternal Grandmother's
Weight
70 Paternal Grandmother's Eye
Color
71 Paternal Grandmother's Hair
Color
72 Paternal Grandfather's Ethnic
Ancestry (French, English,
German, etc.)
73 Paternal Grandfather's Height
(inches)
74 Paternal Grandfather's Weight
75 Paternal Grandfather's Eye
Color
76 Paternal Grandfather's Hair
Color
77 Number of sisters
78 Number of brothers
140
blue
blonde
Caucasian
n/a
n/a
blue
blonde
2
1
Personal Health/Social History
79 History of Fertility Problems?
80 If yes, list in detail nature of
fertility problems
81 Year of high school graduation
82 SAT score if taken
83 Name of college
attending/attended
84 Number of years of college
completed
85 Did you graduate?
86 College Major/Minor
87 GPA
88 If you did not complete school
and are not currently attending
one, please explain why. You can
also use this area to give any
additional information.
89 Current Occupation
No
none
2004
n/a
n/a
0
Yes
none
3.5
home maker
after both my children start school I want to go
to school to become a ultra sound tech
91 Toxic Chemical Exposure
No
92 If Yes, list detail of exposure
none
93 Food Allergies?
none
94 If yes, list allergy and reaction none
95 Drug Allergies?
pennicillin
96 If yes, list allergy and reaction. i sweal up
97 Plant/Environmental Allergies? none
98 If yes, list allergy and reaction. none
99 Do you suffer from a hearing
No
impairment?
100 If yes, detail impairment
none
I go to the gym 5 days a week I do a hour in
101 Exercise regimen
weight room and 40 minutes in cardio room
102 Have you ever had surgery?
No
103 If yes, list dates/types of
none
surgery and reasons for surgery
104 Have you ever been
hospitalized for any reason
No
(including psychiatric
hospitalizations)?
105 If yes, list dates/reasons for
none
hospitalizations
106 Have you ever been treated for
No
an STD?
107 If yes, list STD, date of
treatment, and what treatment
none
was given?
108 Have you suffered from any
No
major illness (i.e. mononucleosis)?
109 If yes, list date of illness,
none
including dates.
110 Chronic Medical Conditions? No
111 If yes, list details of condition none
112 Overseas military
none
service/dates of service?
Name of Substanc
Start Date:
113 Please list any prescription,
non-prescription or recreational End Date:
Frequency:
drugs used in the past 5 years?
90 Career goals
114 Alcohol use?
115 Do you smoke cigarettes?
116 Have you smoked cigarettes in
the past?
117 If yes, list month and year you
stopped smoking.
118 Tested for HIV?
119 Willing to be tested for HIV?
120 Spouse / Partner willing to be
tested for HIV?
121 Have you ever had a blood
transfusion?
122 Do you have any genetic
Defects?
123 If yes, list detail of genetic
defect
124 Jewish Ancestry?
125 If yes, tested for Tay Sachs?
126 Black Ancestry?
127 If yes, tested for Sickle Cell
Anemia?
128 Mediterranean Ancestry?
129 If yes, tested for Thalassemia?
130 At what age did you begin
menstruating?
131 What was the date of your
most recent period?
132 How frequently do you get
your period (i.e. every 28 days)?
133 How many days do you
typically flow?
134 Have your periods ever been
irregular?
135 Are your periods regular
currently?
136 Have you ever been pregnant?
137 If yes, list dates of
Name of Substanc
Start Date:
End Date:
Frequency:
Yes (how many drinks per week?): - 1-2 glasses
of wine
No
No
dont smoke
No
Yes
Yes
No
No
none
No
No
No
No
No
No
12
06-04-2012
every 28 days
4-5 days
No
Yes
Yes
01-01-2005 and 06-01-06
pregnancies.
138 Dates of deliveries
139 Have you ever given a child up
for adoption?
140 Have you ever had an
abortion?
141 If yes, list date of abortion
142 Have you ever suffered a
miscarriage?
143 If yes, list date of miscarriage.
144 Have you ever been an egg
donor before?
145 If yes, list dates details
previous donations (you will be
asked to provide complete
donation records for review).
146 How many sexual partners
have you had?
147 How many sexual partners
have you have in the last year?
148 Have you had sex with anyone
who has the HIV virus?
149 What is your present form of
birth control?
150 Do you always practice safe
sex?
151 Have you ever experienced any
of the following traumas?
152 If yes, please explain
circumstance of trauma and
treatment given.
10-31-2005 and 03-27-2007
No
No
none
No
none
No
1
1
No
none
Yes
None of the above
none
I Have a family friend who was having a hard
time getting pregnant she started looking into
getting a donor egg and the agency she went
153 Why do you want to be an egg
though was so helpful in finding her the right
donor?
egg, she is now a mother to a beautiful baby boy
I want to be able to help someone get to where
she is.
well I think I'm a very attactive women I have no
154 Why do you think you’d
health problems my own children are healthy
make a good donor? Why should a
and absolutly beautiful , I have never had issues
recipient choose you as their
with weight gain, I never had any issues in
donor?
school, I'm a clean and orginized person, animal
lover, I get along with everyone I think I am a
well rounded individual.
155 What do you think you will
I will gain the happiness by knowing i did
gain personally from being an egg
something good for a deserving parent
donor?
156 How many times do you think
maybe 2 or 3 times
you'd like to donate?
I love animals I see one I want to take it home
157 Please give a brief description but my husband says no haha, I love children , I
of your personality. Include any
am the one in my family that gets everyone
qualities about yourself that you together for hollidays and birthdays, I think I
think are unique and special to
have a good sense of humor, I am not a
you.
judgmental person at all, im very caring, Im the
master of multi tasking
158 What are your interests and
I love working out with my husband, and
hobbies?
helping out in my daughters school
159 Do you have musical skills?
No
160 If yes, what are they?
none
161 Do you have artistic talents?
No
162 If yes, what are they?
none
163 Do you have athletic abilities? Yes
I was a cheerleader in high school, I run and i
164 If yes, what are they?
played softball with my gym
165 Do you have any pets? What
Yes - 2 dogs 1 cat
kind?
166 What languages do you speak? english
167 What are your future goals and
I want to become ultra sound tech
aspirations?
168 What is your best quality?
multi tasking
169 What is your worst quality?
I dont know
170 Please check any of the life
None of the above
stresses you have had:
171 If you checked any life stresses,
none
how did you cope with those?
172 Have you ever been medicated
for depression, anxiety, or any
No
other mental illness?
173 If yes, please list medications
taken and dates used, including
stop dates.
174 What does it mean to you to
I dont feel like Im giving up my eggs i feel like
give up your eggs?
Im giving the gift of becoming a parent
175 Will you feel like a mother to
the child/children born from your no
eggs?
I feel like my relationship to the child is what
176 If a child is born from your
the childs parent decides it is , Im just the
eggs, what is your relationship to
person who helped their mother of father get the
that child?
chance to be a parent
177 Would you want an
anonymous relationship with the if their comfortable meeting i would to meet the
recipient couple or would you
inteded parents
want to meet them?
178 If the couple who selects you
wanted to meet you, would you be yes
willing to meet them?
179 Would you want an ongoing
If the inteded parent wanted to keep in touch
relationship with the couple after
absolutly
the donation?
180 If a child born from your
donation wanted to talk to you or
yes
meet you someday, would you be
willing to do so?
181 Please check any of the
following you think you would
None of the above
have difficulty with as part of the
donation process:
182 Please elaborate your
concerns for any item checked
above
183 Would you want to know if a
pregnancy resulted from your
Yes - just to know if i really helpped someone
donation? Why or why not?
184 Would you want to know
Yes - if the parents were comfortable with me
when the baby is born? Why or
knowing
why not?
185 Who have you told about your
My mother and husband
plans to donate?
186 What do they think about your
they have been completely supportive
plans?
187 Have you told your parents? Yes
188 Why or why not? Please
I told them I wanted to help someone enjoy
explain how you think your
their baby like I enjoy my own children. they
parents would react to your
thought I was doing it for the right reasons
decision to donate.
189 Please describe your
I have a wonderful relationship with my parents
relationship with your parents
today.
190 Who will be your support
system when you go through the my husband Jeff
procedure?
191 If you are married or in a
significant relationship, is your
Yes
partner supportive of your plans to
donate?
Detailed Family Health History
192 Heart disease (from birth)
193 Heart disease defect (other)
194 Heart Attack
195 High blood pressure
196 Anemia
197 Sickle-cell anemia
198 Hemophilia or other bleeding
problems
199 Leukemia
200 Immune Deficiency
201 Other blood disorders
202 Hay Fever
203 Asthma
204 Hardening of the arteries
205 Tuberculosis
206 Lung Cancer
207 Pneumonia
208 Other lung disease
209 Acne
210 Eczema
211 Skin Cancer
212 Pigmentation disorders
213 Melanoma
214 Emphysema
215 Kidney disease
216 Bladder cancer
No One
No One
No One
No One
Mother
No One
No One
Others
No One
No One
No One
No One
No One
No One
No One
No One
No One
No One
No One
No One
No One
No One
No One
No One
No One
217 Other urinary disorders
218 Ulcers
219 Gall stones
220 Hepatitis A (infectious)
221 Hepatitis B (serum)
222 Other liver disease
223 Colon Cancer
224 Other skin disorders
225 Crohn's disease
226 Intestinal cancer
227 Undescended testicle
228 Hypospadias
229 Prostate cancer
230 Uterine fibroids
231 Ovarian cysts
232 Cervical cancer
233 Uterine cancer
234 Ulcerative Colitis
235 Hypoglycemia
236 Thyroid cancer
237 Thyroid disease
238 Goiter
239 Adrenal dysfunction
240 Other endocrine disorder
241 Migraines
242 Mental retardation
243 Senility before age 50
244 Diabetes mellitus
245 Multiple sclerosis
246 Cerebral palsy
247 Epilepsy or seizures
248 Water on the brain
249 Spinal cord disorders
250 Huntington's disease
251 Other neurological disorders
252 Schizophrenia
253 Manic depression
254 Alzheimer's disease
No One
No One
No One
No One
No One
No One
No One
No One
No One
No One
No One
No One
No One
No One
No One
No One
No One
No One
No One
No One
No One
No One
No One
No One
No One
No One
No One
No One
No One
No One
No One
No One
No One
No One
No One
No One
No One
No One
255 Mental disorders requiring
No One
hospitalization
256 Nervous breakdown
No One
257 Suicide attempt
No One
258 Use of psychiatric medications No One
259 Anxiety/panic attacks
No One
260 Phobia(s)
No One
261 Eating disorders
No One
262 Psychotherapy/counseling
No One
263 Alcoholism
No One
264 Severe depression with
No One
inability to function
265 Other mental disorders
No One
266 Muscular dystrophy
No One
267 Lupus
No One
268 Deformity of spine
No One
269 Osteoporosis
No One
270 Dwarfism
No One
271 Arthritis
No One
Sibling
272 Gout
No One
273 Other muscle/bone disorders No One
274 Drug abuse/addiction
No One
275 Significant hearing loss
No One
276 Deformity of the ears
No One
277 Cataracts before 50
No One
278 Blindness
No One
279 Glaucoma
No One
280 Color blindness
No One
281 Deviated septum
No One
282 Other sensory disorders
No One
283 Breast cancer
No One
284 Any cancer(s) not listed
No One
285 Deafness before 60
No One
286 Please list your mother's age,
health problems, age at diagnosis
of health problems, and whether my mother is 46 has no heath problems and is
she is living or deceased. If
still living and very active
deceased, give age at death and
cause of death.
287 Please list your father's age,
health problems, age at diagnosis
of health problems, and whether my father is 52 has no health problems and is
he is living or deceased. If
still alive
deceased, give the age at death and
cause of death.
288 Please list your sister(s)' age,
health problems, age at diagnosis
My sister Alyssa is 22 no health problems and
of health problems, and whether
still alive my sister Tyler is 16 no health
they are living or deceased. If
problems and is still alive
deceased, give the age at death and
cause of death.
289 Please list your brother(s)'
age, health problems, age at
diagnosis of health problems, and my brother dustin is 23 no health problems and
whether they are living or
still alive
deceased. If deceased, give the age
at death and cause of death.
290 Please list your mother's
mother's age, health problems, age
at diagnosis of health problems,
my grandmother betty is 63 no health problems
and whether she is living or
and is still alive
deceased. If deceased, give the age
at death and cause of death.
291 Please list your mother's
father's age, health problems, age
my grandfather is 65 had leukiemia at age 54
at diagnosis of health problems,
has been in remission for the las 8 years has no
and whether he is living or
current health problems and is still alive
deceased. If deceased, give the age
at death and cause of death.
292 Please list your mother's
sister(s)' age, health problems, age
my aunt amanda is 34 no health problems still
at diagnosis of health problems,
alive my aunt jessica is 40 no health problems
and whether they are living or
sill alive
deceased. If deceased, give the age
at death and cause of death.
293 Please list your mother's
brother(s)' age, health problems,
age at diagnosis of health
my uncle Anthony is 36 no health problems still
problems, and whether they are
alive my uncle Garrett is 34 no health problems
living or deceased. If deceased,
still alive
give the age at death and cause of
death.
294 Please list your father's
75 Healthy
father's age, health problems, age
at diagnosis of health problems,
and whether he is living or
deceased. If deceased, give the age
at death and cause of death.
295 Please list your father's
mother's age, health problems, age
at diagnosis of health problems,
and whether she is living or
deceased. If deceased, give the age
at death and cause of death.
296 Please list your father's
sister(s)' age, health problems, age
at diagnosis of health problems,
and whether they are living or
deceased. If deceased, give the age
at death and cause of death.
297 Please list your father's
brother(s)' age, health problems,
age at diagnosis of health
problems, and whether they are
living or deceased. If deceased,
give the age at death and cause of
death.
298 Please list any other relevant
information about health
problems your family members
had.
299 Have you ever been involved
in a lawsuit? Please describe fully,
including the dates, the reason
and outcome
300 Have you or anyone in your
family ever been arrested?
301 If yes, who?
302 Please describe fully,
including dates and reasons.
74 Healthy
two sisters in their 40 no health problems still
alive
no brothers
none
No
Yes
my husband got arrested in 05 for DUI
he was driving home after a work related get
together got pulled over and was just over legal
limit it was in 05
303 Has anyone in your family,
including yourself, ever been
No
convicted of a criminal offence?
304 If yes, who?
305 I warrant that all information
I have provided in this application Yes
to Circle Surrogacy and its
representatives is to the best of my
knowledge true and correct. I
understand that this information
will be used to evaluate me as
potential donor