Egg Donor Pre-Screening Questionnaire

Welcome, and thank you for your interest in becoming an egg donor. To help determine your initial eligibility, please complete the following screening form honestly and thoroughly.

1. Basic Eligibility

Full Name

dATE OF bIRTH

height

weight (lbs)

BMI (optional)

u.s citizenship statusU.S CitizenLegal Resident

do you speak and understand english fluently?YesNo

do you have a valid government-issued id?YesNo

2. Reproductive History

Have you donated eggs before?YesNo

Are your menstrual cycles regular (every 24–35 days)?YesNo

Are you currently using birth control?YesNo

Have you ever been pregnant?NoYesLive birthMiscarriageAbortion

3. Health & Medical History

Do you have any known genetic disorders or inherited conditions in your family?YesNo

Do you take any prescription medications regularly?YesNo

Do you have any chronic medical conditions (e.g., diabetes, epilepsy, asthma)?YesNo

Do you or any immediate family members (parents, siblings, grandparents) have a history of the following? (Check all that apply)CancerHeart diseaseMental illnessDiabetesGenetic disordersSubstance abuse

4. Lifestyle Factors

Do you smoke or use nicotine products?YesNo

Do you use recreational drugs?YesNo

Do you consume alcohol?YesNo

Have you ever had a sexually transmitted infection (STI)?YesNo

Are you currently in good physical and mental health?YesNo

5. Education and Background

Ethnic background

Highest level of education completed:High SchoolSome CollegeBachelor’s degreeGraduate Degree

Languages spoken

Do you have a flexible schedule for screening and appointments over a 2–3 month period?YesNo

6. Consent & Agreement

I understand that this is a preliminary screening and that I may be contacted for further evaluation.Yes

I affirm that all the information provided is truthful to the best of my knowledge.Yes

signature

Date of signature

Message

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Name

Company

Message

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