Dear Applicant,
Thank you for considering egg donation to help others in need. Enclosed is the application
packet, which begins with standard screening questions, followed by the Egg Donor Profile. Please
send the completed and signed forms, along with pictures of you (childhood + adult), and of your
children (if applicable) to:
by fax:
949.679.8788
Attention: Robin
by email:
info@OptionsinConception.com
or by mail:
Options in Conception
16300 Sand Canyon Ave. Suite 903
Irvine, CA 92618
If you have any questions, please feel free to call us. Thank you.
Sincerely Yours,
The Team at Options in Conception
English: 949.533.4286
Chinese: 626.388.7606
Korean: 714.833.7478
1
initial screening questions
Egg Donor 
Intended parent 
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
Y
N
Have you injected drugs for a non-medical reason in
the last 5 years, including intravenous,
intramuscular, or subcutaneous injection?
Do you have a clotting disorder for which you have
received human-derived clotting factor
concentration?
Have you had sex for drugs or money in the past 5
years?
In the past 12 months, have you given money or
drugs to anyone to have sex with you?
Have you had sex in the past 12 months with
anyone who would answer yes to the above 4
questions?
Female: In the past 12 months, have you had sex
with a man who has had sex with another man in the
past 5 years?
Male: Have you had sex with another male in the
past 5 years?
In the past 12 months, have you had sex with a
person known or suspected to have HIV, or active
hepatitis B or C?
In the past 12 months, have you been exposed to
known or suspected HIV, hepatitis B, and/or
hepatitis C infected blood through pericutaneous
inoculation, contact with an open wound, non-intact
skin, or mucous membrane?
In the past 12 months, have you been in close
contact (i.e. sharing kitchen and bathroom) with a
person having active viral hepatitis?
In the past 12 months, have you had tattooing, ear or
body piercing in which shared instruments were
used?
After the age of 11, have you ever had viral
hepatitis (Hep A excluded: IgM anti-HAV test)?
Have you yourself received or had intimate contact
(i.e. exchanged body fluids, including sharing
toothbrushes and razors) with someone who has
received organs or cells from non-human sources?
Have you had a recent smallpox vaccination
In the past 4 weeks have you had any shots or
vaccinations?
Have you been diagnosed with West Nile Virus
(defer at least 28 days from date of diagnosis or 14
days from the date condition is resolved; whichever
is later)?
2
DON’T
KNOW
Comments
Questions
16. Have you had a blood transfusion or infusion within
the past 48 hours before your blood test for
eligibility? If so, algorithms must be used to
determine if plasma dilution is a problem.
17. Have you ever received growth hormone made from
human pituitary glands?
18. Have you ever received a dura mater (brain
covering) graft?
19. Have any of your blood relatives ever had
Creutzfeldt-Jakob disease?
20. In the past 12 months, have you had a positive
syphilis test?
21. In the past 12 months, have you had or been treated
for syphilis or gonorrhea?
Y
N
22. In the past 12 months, have you been in jail for
more than 3 days in a row?
23. From 1980 through 1996, were you a member of the
US military, a civilian military employee or a
dependent of a member of the US military?
24. Since 1980, have you ever lived in or traveled to
Europe? (Includes: England, Ireland, Scotland,
Wales, the Isle of Man, the Channel Islands,
Gibraltar, or the Falkland Islands)
25. Have you been in a place affected by SARS or with
an affected person with in the past 14 days?
26. Have you been treated for SARS in the last 28 days?
27. Were you born in, have you lived in, or have you
traveled to any African country since 1977?
28. When you traveled to _______, did you receive a
blood transfusion or any other medical treatment
with a product made from blood?
29. Have you had sexual contact with anyone who was
born in or lived in any African country since 1977?
Patient (print)
Date
/
Signature
/
Time
:
Witness (print)
Date
/
AM
PM
AM
PM
Signature
/
Time
:
Office Use Only.
Accept 
Reject 
Physician ___________________________________
Date _______________ Time ___________________
3
D/K
Comments
EGG DONOR PROFILE
THE INFORMATION ON THIS PAGE WILL BE KEPT CONFIDENTIAL.
Date Form Completed:
Name:
AKA:
Date of Birth:
/
/
Age:
Address:
City:
State:
Zip:
Home phone: (
)
-
Cell: (
)
-
Work phone: (
)
-
Fax: (
)
-
Email:
Driver’s License Number:
Social Security number:
US Citizen:
Yes
Occupation:
Employer:
State:
No
Health Insurance Carrier:
Policy Holder:
Group #:
Policy #:
Emergency Contact:
Phone Numbers: (
Marital Status:
Relationship:
)
-
Married
and (
Single
)
Divorced
Separated
Widowed
Committed Relationship
Name of partner:
Partner’s Date of birth:
/
/
Partner’s Social Security number:
What are your favorite stores to shop or restaurants to eat at?
How did you hear about us?
Do you have reliable transportation?
4
/
/
EGG DONOR PROFILE
THE FOLLOWING INFORMATION WILL BE INCLUDED IN YOUR PROFILE.
BASIC INFORMATION
Age:
Occupation:
Blood type:
Confirmed Date:
Religious background:
Marital status:
Married
Single
Divorced
Separated
Widowed
Committed Relationship
PHYSICAL DESCRIPTION
Height:
Weight:
Eye color:
Hair texture:
Straight
Complexion:
Fair
Physical build:
Petite
Predominant hand:
Natural hair color:
Wavy
Curly
Thin
Medium
Olive
Dark
Average
Heavy
Right handed
Average
Thick
Freckles
Other
Left handed
Ambidextrous
ETHNIC ORIGIN (please be specific – French, Chinese, German, etc.)
Maternal:
Paternal:
EDUCATION
Years of high school completed:
Years of college completed:
GPA:
SAT Score:
GPA:
Post-Graduate Education:
Major:
Degree:
Educational goals:
Have you had an IQ test?
Yes
No
Do you have any learning disabilities?
If yes, list date and scores:
Yes
No
If yes, please explain:
DONATION HISTORY
Have you been an egg donor previously?
How many eggs were retrieved?
Yes
No
If yes, how many times?
Did a pregnancy occur?
Yes
No
Don’t know
PERSONALITY
Which of the following describes you best? Check all that apply:
Extrovert
Slight extrovert
Aggressive
Assertive
Independent
Dependent
Shy
Other:
Please describe your childhood:
Introvert
Passive
Please describe your personality and character:
What are your favorite books?
What are your favorite movies?
What is your favorite color?
5
Slight introvert
Energetic
Warm
Happy
Sensitive
Moody
Lonely
Quiet
What are your favorite foods?
What was your favorite subject in school?
Please describe any special talents, skills, or abilities you have:
What languages do you speak?
What kind of sports, activities, and/or hobbies do you enjoy?
Where would you like to travel to and why?
Who are the most important people in your life?
What is your philosophy in life?
What is the reason you want to be an egg donor?
Is there anything else you would like to tell us about yourself?
MENSTRUAL HISTORY
Present form of birth control:
Do you have regular, predictable menstrual periods?
Yes
No
How often do you have menstrual periods?
Every
days my period comes. It lasts
days.
PREGNANCY HISTORY
Have you ever been pregnant?
Yes
No
For all previous pregnancies (including abortions and miscarriages). Please list the following information:
Year
Type Delivery
Outcome
Complications
1.
2.
3.
4.
5.
Have you ever had trouble getting pregnant?
Yes
No
If yes, please explain:
Did your parents have difficulty conceiving?
Yes
No
Do any of your family members, including siblings, have fertility issues?
Yes
No Explain:
YOUR CHILDREN
1.
2.
3.
4.
5.
Female
Male
Any health problems?
Female
Male
Any health problems?
Female
Male
Any health problems?
Female
Male
Any health problems?
Female
Male
Any health problems?
No children
Hair color:
Eye color:
Hair color:
Eye color:
Hair color:
Eye color:
Hair color:
Eye color:
Hair color:
Eye color:
HEALTH INFORMATION
Blood type:
RH factor:
Positive
Negative
Are you under a physician’s care for any reason?
Yes
No
If yes, please explain:
Current medications (include vitamins, aspirin, antacids, etc.)
Medication
Frequency
Reason
1.
2.
3.
4.
List all allergies and your reaction to each:
Allergen
Reaction
1.
6
2.
3.
Do you wear glasses or contact lenses?
Yes
No
What is the condition of your teeth?
Excellent
Good
Fair
Poor
How is your diet?
Vegetarian
Non-vegetarian
Excellent
Good
Fair
Are you adopted?
Yes
No
If yes, do you know your medical history?
Yes
Please list any significant illnesses you have had:
Were you ever hospitalized as a child or adult?
Yes
No
If yes, please explain:
Do you ever smoke cigarettes?
Yes
No
If yes, how many per day?
Do you drink alcohol?
Yes
No
If yes, how many drinks per week?
Do you have any history of alcohol abuse?
Yes
No
If yes, please explain:
Have you ever used IV drugs?
Yes
No
If yes, please explain:
Have you ever been under the care of a psychiatrist?
Yes
No
If yes, please explain:
Have you ever been convicted of a crime/felony?
Yes
No
If yes, please explain:
Have you had any body piercing or tattoos?
Yes
No Date:
/
/
Have you had a smallpox vaccination?
Yes
No Date:
/
/
Have you ever been treated for syphilis or gonorrhea?
Yes
No
If yes, please explain:
Have you or any of your partners had the following diseases?
Myself/Partner
Non-specific Urethritis
Yes
No
Myself
Partner
Chlamydia
Yes
No
Myself
Partner
Venereal Warts
Yes
No
Myself
Partner
Herpes
Yes
No
Myself
Partner
Other STD
Yes
No
Myself
Partner
Poor
No
When
EXERCISE INFORMATION
How much exercise do you get?
What type of exercise?
Regular
Occasional
None
MEDICAL HISTORY
Check if you have or have ever had:
Yes
Cancer
Diabetes
Hypertension
High cholesterol
Heart disease
Scarlet fever
Mitral valve prolapse
Heart murmur
Psychiatric disorder
Seizures
Stroke
Blood clots in legs/lungs/heart
Bleeding disorder
Anemia
Thyroid disorder
Recent immunization
Yes
Asthma
Pneumonia
Bronchitis
Tuberculosis
Hepatitis/Liver disorder
Ulcers
Colitis/Enteritis
Kidney disorder
Rubella
Measles
Mumps
Chicken pox
Mononucleosis
Serious injury/accident
Blood transfusion
Anesthetic complication
7
No to All of the above
If you answered yes to any of the above, please explain:
Yes
Wear glasses
Wear contact lenses
Double vision
Blind spots
Unable to smell
Sinus problems
Hayfever
Ringing in ears
Hearing loss
Denture/bridge
Chest pain
Irregular heartbeats
Fainting spells
Leg swelling
Calf pain
Varicose veins
Yes
Prolonged bleeding
Bleeding from gums
Nose bleeds
Take aspirin/ibuprofen frequently
Breast discharge
Breast mass
Fibrocystic changes
Breast implants
Mammogram
Do monthly breast self exam
Excessive hair growth
Acne
Skin disorder
Rash
Hives
Skin cancer
Cough
Shortness of breath
Wheezing
Cough up blood
Chest x-ray
TB skin test
Abdominal pain
Nausea and vomiting
Vomiting blood
Ulcer
Food intolerance
Gallstones
Jaundice/Hepatitis
Chronic constipation
Diarrhea
Blood in bowel movement
Irritable bowel
Colitis/Enteritis
Hernia
Hemorrhoids
Abnormal liver function tests
Bowel x-ray
Bladder infections
Kidney infection
Painful urination
Urgent/frequent urination
Blood/abnormal color of urine
Unable to control urination
Abnormal urinary tract
Kidney x-ray
Bladder cystoscopy
Anemia
Easy bruising
Yes
Bowel endoscopy
Heat or cold intolerance
Arthritis
Disc disease
Back pain
Yes
Nerve/head injury
Sensation loss/numbness
Muscle control/weakness
Recent weight change
Enlarged thyroid
Abnormal thyroid function
Counseling
Psychiatric treatment
Recent stress increase
Recent anxiety increase
Damp skin
Unusual hair loss
Extraordinary fatigue
NO to All of the above.
Headaches:
Yes
No
Mild
Improving
If yes, number per week
Moderate
Worsening
Medication used
Severe
Stress related
No change
Migraine
8
With visual changes
With vomiting
FAMILY HISTORY
Check if you or anyone in your family ever had:
Yes
Neutral tube defects/Spina
Bifida/Anencephaly
Thalassemia
Down syndrome
Autism
Canavans
Gauchers
Sickle cell disorder or trait
Alzheimer’s disease
Tay-Sach’s disease
Club foot
Parkinson’s disease
Cancer
Hypertension
Heart disease
Yes
No
Cystic fibrosis
Muscular dystrophy
Huntington chorea
Mental retardation/Fragile X
Chromosomal disorder
Congenital heart defect
Baby with birth defects
Hemophilia
Cerebral palsy
Cleft palate/lip
Deafness
Multiple sclerosis
Diabetes
High cholesterol
Stroke
If so, which family member?
Explanation:
Others:
MOTHER
Current age:
Ethnic ancestry:
Heights:
Eye color:
Natural hair color:
Hair texture:
Straight
Wavy
Curly
Complexion:
Fair
Medium
Olive
Level of education:
Occupation:
Special skills, talents, or interests:
Personality traits:
General health:
Age at death and cause of death (if applicable):
Thin
Dark
Average
Freckles
Thick
FATHER
Current age:
Ethnic ancestry:
Heights:
Eye color:
Natural hair color:
Hair texture:
Straight
Wavy
Curly
Complexion:
Fair
Medium
Olive
Level of education:
Occupation:
Special skills, talents, or interests:
Personality traits:
General health:
Age at death and cause of death (if applicable):
Thin
Dark
Average
Freckles
Thick
MATERNAL GRANDMOTHER
Current age:
Ethnic ancestry:
Heights:
Eye color:
Natural hair color:
Hair texture:
Straight
Wavy
Curly
Complexion:
Fair
Medium
Olive
Level of education:
Occupation:
Special skills, talents, or interests:
Personality traits:
General health:
Age at death and cause of death (if applicable):
9
Thin
Dark
Average
Freckles
Thick
MATERNAL GRANDFATHER
Current age:
Ethnic ancestry:
Heights:
Eye color:
Natural hair color:
Hair texture:
Straight
Wavy
Curly
Complexion:
Fair
Medium
Olive
Level of education:
Occupation:
Special skills, talents, or interests:
Personality traits:
General health:
Age at death and cause of death (if applicable):
Thin
Dark
Average
Freckles
Thick
PATERNAL GRANDMOTHER
Current age:
Ethnic ancestry:
Heights:
Eye color:
Natural hair color:
Hair texture:
Straight
Wavy
Curly
Complexion:
Fair
Medium
Olive
Level of education:
Occupation:
Special skills, talents, or interests:
Personality traits:
General health:
Age at death and cause of death (if applicable):
Thin
Dark
Average
Freckles
Thick
Thin
Dark
Average
Freckles
Thick
PATERNAL GRANDFATHER
Current age:
Ethnic ancestry:
Heights:
Eye color:
Natural hair color:
Hair texture:
Straight
Wavy
Curly
Complexion:
Fair
Medium
Olive
Level of education:
Occupation:
Special skills, talents, or interests:
Personality traits:
General health:
Age at death and cause of death (if applicable):
SIBLING
Sister
Brother
Current age:
Height:
Eye color:
Natural hair color:
Hair texture:
Straight
Wavy
Curly
Complexion:
Fair
Medium
Olive
Level of education:
Occupation:
Special skills, talents, or interests:
Personality traits:
General health:
Age at death and cause of death (if applicable):
Thin
Dark
Average
Freckles
Thick
Thin
Dark
Average
Freckles
Thick
SIBLING
Sister
Brother
Current age:
Height:
Eye color:
Natural hair color:
Hair texture:
Straight
Wavy
Curly
Complexion:
Fair
Medium
Olive
Level of education:
Occupation:
Special skills, talents, or interests:
Personality traits:
General health:
10
Age at death and cause of death (if applicable):
SIBLING
Sister
Brother
Current age:
Height:
Eye color:
Natural hair color:
Hair texture:
Straight
Wavy
Curly
Complexion:
Fair
Medium
Olive
Level of education:
Occupation:
Special skills, talents, or interests:
Personality traits:
General health:
Age at death and cause of death (if applicable):
Thin
Dark
Average
Freckles
Thick
Thin
Dark
Average
Freckles
Thick
Thin
Dark
Average
Freckles
Thick
SIBLING
Sister
Brother
Current age:
Height:
Eye color:
Natural hair color:
Hair texture:
Straight
Wavy
Curly
Complexion:
Fair
Medium
Olive
Level of education:
Occupation:
Special skills, talents, or interests:
Personality traits:
General health:
Age at death and cause of death (if applicable):
SIBLING
Sister
Brother
Current age:
Height:
Eye color:
Natural hair color:
Hair texture:
Straight
Wavy
Curly
Complexion:
Fair
Medium
Olive
Level of education:
Occupation:
Special skills, talents, or interests:
Personality traits:
General health:
Age at death and cause of death (if applicable):
CONFIDENTIAL
The following information will be kept confidential.
Are you able to comply with the following requirements:
Egg donors are required to have infectious disease screening tests at the expense of the
Prospective recipients/parents.
Yes
No
Egg donors must abstain from sexual activity while undergoing the egg donation cycle unless they have had
a Tubal Ligation or their partner has had a vasectomy.
Yes
No
Egg donors are required to attend approximately 8 to 10 appointments throughout the donation cycle.
Yes
No
Egg donors are required to take self-administered injections for approximately three weeks.
Yes
No
Egg donors are required to undergo a procedure under sedation to remove the eggs from their ovaries.
11
Yes
No
Egg donors are required to have reliable transportation for appointments.
Yes
No
Egg donors are required to have a driver on the day of the egg retrieval.
Yes
No
No legal fees, psychological testing fees, medical testing fees or medical procedure fees will be charged to
the applicant or her partner. However, any expenses incurred (mileage, babysitting, etc) while applying to the
program and throughout the egg donation process are the responsibilities of the egg donor.
I consent to being notified of any medical information discovered about me during the egg donation process.
I AUTHORIZE THE RELEASE OF ANY NON-FICTIONAL INFORMATION AND PHOTOGRAPHIC MATERIAL
ENCLOSED IN THIS APPLICATION.
I CERTIFY THAT ALL THE INFORMATION PROVIDED IS COMPLETE AND TRUE TO THE BEST OF MY
KNOWLEDGE.
Name of the egg donor applicant (print)
Signature of egg donor applicant
Date
Name of witness (print)
Signature of witness
Date
12