莲花医疗美国诊所捐卵申请表 Lotus Fertility-Clinic Egg Donation-Donor Application Form
填表人须保证以下信息的真实性 The preparer must ensure the authenticity of the following information: Webstie: English: https:/www.goldenlotusconnections.com/ 中文: https://www.goldenlotusconnections.com/zh Email: info@goldenlotusconnections.com
基本资料 BasicInformation
姓名 Name：
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电子邮箱 Email：
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example@example.com
个人联系电话 Personal Phone number:
居住国家或地区 From which Country or Region：
国籍 Nationality：
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出生年月 Date of Birth：
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Month
-
Day
Year
Date
血型 Blood Type：
身高 Height ：
体重Weight：
眼睛颜色 Eye Color：
发色 Hair Color：
种族 Race：
学历 Education：
学校名称及专 业 School Name& Major：
学科成绩 General Weighted Average GPA：
其他特长 Other Expertise：
婚姻状况 Marital status：
运动习惯 Exercise habit：
性格特点 Personality：
是否做过整形 Have you had plastic surgery？
是否有捐卵经验 Have you been an egg donor in the past?
脸书或其他社交平台网页 Facebook or Social Media Page:
开放式问题 Open Questions
在你家里成长是什么感觉 What was it like growing up in your family?
最喜欢的运动 What is your favorite sport?
描述以下你有什么任何特殊才能，技能，爱好，和兴趣 Describe any special talents, skills, hobbies or interests you have:
你最喜欢的书和为什么喜欢 What is your favorite book and why?
你最不喜欢什么 What are your dislikes?
你的人生终极目标和抱负 What is your ultimate goal and ambition in life?
你为什么想当一名捐卵者 Why do you want to be an egg donor?
你最喜欢的食物是什么？What’s your favorite food?
家 庭信息 Family information
是否是收养子女？Are you adopted?
No
Yes
Type a question
年龄 Age
体重 Weight
种族 Race
职业 Occupation
健康状况 Health
父亲 Father
母亲 Mother
祖父 Paternal grandfather
祖母 Paternal grandmother
外祖父 Maternal grandfather
Listen
外祖母 Maternal grandmother
祖辈信息尽量填写详细，如年龄，健康状况，如已故填写原因 Please fill in as much details for parents and grandparents as possible, such as age, health status, and the reason for death
医疗背景 Medical information
是否有过重大疾病?Have you had any major illness?
No
Yes
是否有过住院/手术？Describe any hospitality or surgeries you have had.
No
Yes
是否有慢性病？Do you have any chronic medical problems or conditions?
No
Yes
是否有性疾病？Have you ever had sexually disease?
No
Yes
是否有精神方面問題？Have you ever been under the care of psychiatrist ?
No
Yes
是否近视眼？如果是，请明确具体度数？Do you wear contact or glasses?
No
Yes
是否做过近视矫正手术？Have you ever had Laser surgery?
No
Yes
是否有牙齿问题？或戴过牙套？如果是，请详细说明。Have you ever had dental problem or braces？
No
Yes
是否有听力问题？Have you ever had hearing problem?
No
Yes
是否吸烟？Do you smoke?
No
Yes
是否喝酒？Do you drink alcohol?
No
Yes
是否吸毒?Have you ever taking drug?
No
Yes
是否有过敏史？Do you have any allergies?
No
Yes
是否有纹身或穿孔？Have you had any tattoo or body piercing?
No
Yes
是否有家族遗传病史？Do you have a family hereditary disease?
No
Yes
其他健康问题，如果有 Other pre-existing health condition, if any
生殖资料 Reproductive information
最近一次看妇科时间及结果？When was your last visit to the obstetrics? What wasyour result?
最后一次宫颈抹片的时间及结果？What was the last date of pap smear? Whatwas your result?
是否曾经怀孕过，如果有，几次？How many pregnancies have you had?
目前如何避孕？What is your current contraceptive measures?
生殖资料及检查报告上传，如有 Upload the past test results and/or fertility history report including blood, urine, genetic, ultrasound, etc, if there is any available.
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照片和视频 Pictures and Short Videos
个人照片(6-8张）/儿时照片（1-2张）/一段自我介绍视频 （可选） Personal photo/childhood photo/a self introduction video （Optional)
*
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提交 Submit
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