DONOR APPLICATION QUESTIONNAIRE

GENERAL DONOR INFORMATION:

Complete name:

Age:

Date of birth:

Most donations are anonymous; however sometimes there is flexibility with sharing information.

Would you prefer a completely anonymous donation or are you open to learning more about the Intended Parents or any offspring that resulted from your donation?

Yes: No: Unsure:

Would you provide updates on your medical status that might be relevant to the children that resulted from your donation? Yes: No:

Please keep in mind that the intended parents are on a limited budget so first time donors can expect $2,500USD and the fee can raise incrementally for each subsequent cycle. Do you agree on this?

Yes: No:

Have you lived outside the US between 1982-1996 more than 3 months?

Yes: No:

-ABOUT YOU:

Maternal Ethnic Ancestry:

Paternal Ethnic Ancestry:

Citizen of what country?

Height:

Weight:

Eye color:

Natural hair color:

Natural hair texture:

Skin color (light, medium, medium dark ,dark, asian):

Build thin,(average, overweight):

Genetic issues with teeth?

Braces? Yes: No:

Do you wear corrective lenses/contacts? Yes: No:

Vision:

Hearing:

Blood type:

Relationship status:

Do you smoke? Yes: No: How much?

Activities involved in:

What subjects did you excel in?

Any learning disabilities?

-EDUCATION:

You may be asked to provide transcripts and diplomas and verify all test scores.

Name of the college/university you are attending or have attended:

Dates of attendance: From: To: Location:

From: To: Location:

From: To: Location:

Degrees received:

College major:

Name of high school?

-PERSONAL HEALTH HISTORY

Were you adopted? Yes: No:

If yes, what do you know about your biological medical history?

Do you have health insurance? Yes: No:

If yes, which is the company name?

Have you ever been convicted or arrested for a crime or felony? Yes: No:

If yes, please explain:

Have you or any member of your family ever been under the care of a psychiatrist? (hospitalized, on medication or on going therapy? Yes: No:

If yes, please explain:

Have you or any family member ever received treatment for drugs or alcohol abuse?

Yes: No:

If yes, please explain:

Do you drink alcohol? Yes: No:

If yes, how many drinks per week?

Do you take any non prescription drugs? Yes: No:

Describe your diet:

How many days per week do you exercise?

What types of exercise?

Please check if you have ever used any of the following: (you may be asked to take a drug test)

Caffeine Yes: No:

Tobacco Yes: No:

Alcohol Yes: No:

Marijuana Yes: No:

Cocaine Yes: No:

Other :

Have you ever had any of the following:

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