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Egg Donor Screening Questionnaire
What, exactly, is a prospective egg donor actually asked in the screening process? Some of the questions are obvious, but others — very detailed — might surprise you!
- What is your age, race, height, weight, eye and your natural hair color, including childhood and adult hair color?
- Are you right or left handed? Do you have curly or straight hair?
- Have you ever had acne? If so, to what degree? Did you take any prescription medications for acne?
- Do you wear glasses?
- Do you hve tattoos? When were they done? Was the facility licensed? Did they use new needles for your tattoo(s)?
- Do you have body piercings?
- What is your ethnicity? Your religion? Do you practice that religion? Do you have African, Greek, Italian, Asian, or Jewish ancestors?
- Are you a U.S. Citizen?
- Were you adopted? If so, do you know the medical history of your birth parents?
- Were you created from sperm or egg donation yourself? If so, do you have the medical information on the donors?
- Do you have any distinguishing marks or birthmarks?
- What degrees have you completed? What were your grades? Did you take the SAT or ACT? If so, what was your score? Are you willing to have this verified?
- What were your favorite subjects in school? Did you enjoy it?
- Were you ever in special education classes?
- How about your mom and dad? What level of schooling did they reach? What are their occupations?
- What jobs have you had in the past five years? What would you like to do in the future?
- Are you athletic or are sports not your thing? Have you excelled in any physical activity? Did you win any awards?
- Are you agile or clumsy?
- Are you musical or tone deaf? Artistic? Describe.
- Do you like to read? Write?
- What do you like doing in your spare time?
- Are you moody? Outgoing? Passive? Sensitive? Funny? Quiet? Extroverted? Introverted?
- How do others describe you?
- What is important to you?
- How do you solve personal problems? Are you a quick or deliberate decision-maker?
- What are your sleeping patterns?
- What is your diet consist of on a daily basis?
- What is one thing you dislike?
- What is one thing you like?
- Do you have allergies? What types of allergies?
- Do you or have you ever smoked? If so, how much and for how long?
- Have you been treated for a substance/alcohol abuse problem? If so, explain.
- What is your weekly alcohol intake?
- Have you used marijuana, cocaine, barbiturates, narcotics, etc.?
- Do you take over-the-counter drugs?
- Are you currently under the care of a physician?
- Have you ever been hospitalized? If so, explain.
- Are you currently taking any prescription medications? If so, why and how much?
- What is the duration and cycle of your period? At what age did your period start?
- Have you ever had an abnormal pap test? What was result? Any medical treatment?
- Have you ever filed for bankruptcy?
- Have you ever been convicted or charged with a crime (whether misdemeanor or felony)? Been in prison?
- Are any legal cases pending against you? If so, please explain.
- Are you single, married or divorced/separated? Are you currently sexually active?
- Are you heterosexual, bi-sexual or homosexual? How many partners have you had in the past year?
- How many pregnancies have you had? Do you have any children?
- Have you ever had gonorrhea, kidney disease, venereal warts, blood clots,syphilis, AIDS/HIV, liver disease, Phlebitis, Herpes, Diabetes, Hepatitis B, excessive facial hair/heart disease/henpphailius vaginalis, depression, anxiety, eating disorders, manic depression, schizophrenia, suicide attempt, blood transfusion?
- What is your family’s medical history? Is there any history of stroke, heart attack, heart defects, high blood pressure, anemia, hemophilia, leukemia, Crohn’s disease, colon cancer, hay fever, intestinal cancer, thyroid, hyperactivity, kidney disease, diabetes, hypoglycemia, Parkinson’s, MS, paralysis, cerebral palsy, depression, schizophrenia, muscular dystrophy, lupus, osteoporosis, deafness, blindness, eczema, acne, varicose veins, Tay Sachs, Down’s, breast cancer, obesity, or cleft palate?
- In addition to the above list, do you or anyone your family suffer from any of the following: genetic disorders, autism, mental disorders, or other health issues, including but not limited to cancer, diabetes, loss of a limb, non-genetic disorders, etc.
- Have you ever been an egg donor? If so, please list all clinics you have worked with? Do you know if it was successful?
- Have you ever been screened as an egg donor but did not donate?
- Have you ever been disqualified as an egg donor?