Egg Donor Questionnaire

Egg Donor Questionnaire
Name*

First NameLast Name
Email*
example@example.com
Phone Number*

Country CodeArea CodePhone Number
Date of Birth*

MonthDayYear
Date
Place of Birth: City/Country*
Current Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How did you hear about Eggvise?*
Personal
Ethnicity*
Maternal Heritage (Where is your mother from?)*
Paternal Heritage (Where is your father from?)*
Maternal Grandmother Heritage*
Maternal Grandfather Heritage*
Paternal Grandfather Heritage*
Paternal Grandmother Heritage*
Are you of Jewish (genealogical) heritage?

YesNo
Are you adopted?*

YesNo
Please indicate your religion*
Height*
Weight*
Eye Color*
Natural Hair Color*

BlackBrownBlondeRed
Hair Texture*

StraightCurlyWavy
Complexion*

FairOliveMediumDark
Do you have Freckles?*
Corrective Dental?*
Do you currently wear glasses?*
Marital Status*

SingleMarriedEngagedDivorcedWidowed
Are you a US Citizen or have permeant residency?*

YesNo
If no, what type of visa are you on?*
Where were you born?*
What amount are you seeking as compensation?*
We would love to get to know you a bit more. How would you describe your personality? Tell us how you see yourself and what makes you unique. This will help future parents get to know you better and understand a little more about who you are.*
Tell us, what motivates you to become an egg donor? We would love to know more about what inspires you to make this decision*
What is your favorite type of food?**
If you could say something to Intended Parents, whatmessage would you like them to know?*
Have you donated in the past? If yes, How many times?*
If Yes, Number of Eggs Retrieved?*
Education
Current Level of Education*
Name of the College/University currently attending or attended*
If you attended college or university, what was your (major) main area of study?*
If in US, College Grade Point Average (GPA)*

Please individually rate your aptitudes on each of the following abilities: *

	Poor	Average	Excellent
Mathematical/Analytical Ability
Scientific/Problem-Solving Ability
Artistic/Creative Ability(e.g., drawing, painting, design)
Athletic/Physical Ability(e.g., sports, coordination, endurance)

Current Occupation*
Do you have a learning disability?*
Please list your talents (e.g. Musical /Artistic / Athletic etc.) *
What additional language’s do you speak, read, or write? *
Do you play sports or exercise? please explain.*
How often do you exercise?*
OB-GYN
Do you have both of your ovaries?*
At what age did you first experience your menstrual cycle?*
Do you have a regular menstrual cycle? If not, please describe any irregularities*
Current method of Birth Control.*

Birth Control PillBirth Control PatchBirth Control Ring (NuvaRing, etc.)Birth Control Shot (Depo-Provera)Birth Control Implant (Nexplanon, Implanon)Intrauterine Device (IUD) - HormonalIntrauterine Device (IUD) - CopperMale CondomWithdrawal Method (Pull-Out)Sterilization (Tubal Ligation)Partner’s VasectomyEmergency Contraception (Morning-After Pill)Other
Are you currently sexually active? *
Have you ever been pregnant? *
Did you experience any medical issues during your pregnancy? If so, please provide details.*
How Many Children do you have?*
Are you currently breastfeeding? If yes, please provide details.*
Have you ever had an abortion? If so, please provide details.*
Have you ever had a stillborn baby?*
Have you experienced a miscarriage before?*
Do you currently have or have you ever had any sexually transmitted infections (STIs)? If so, please specify if they were treated by a doctor.*
Have you ever found a lump on your breast before? *
Date of your last pap smear. (If none put N/A)*
What were the results of your last pap smear?*
Medical History
Have you received a COVID-19 vaccine? If yes, please specify the type of vaccine (e.g., Pfizer, Moderna, Johnson & Johnson) and the dates of vaccination, if known.*
Do you follow any specific dietary preferences or restrictions that might affect your health profile?*
Do you follow any specific dietary preferences or restrictions that might affect your health profile?*
Are you currently treating any diseases? If so, please list. *
Are you taking any prescription or over the counter medications? If yes, please explain*
Have you been tested as a carrier of Thalassemia? If yes, please explain.*
Have you been tested for being a Cystic Fibrosis carrier? If yes, please explain. *
Have you been tested as a carrier for the Sickle Cell disease? If yes, please explain*
Have you gotten any tattoos in the past 12 months?

YesNo
Have you had any piercings in the past 12 months?

YesNo
Have you ever been diagnosed with cancer?*

YesNo
Do you have any birth defects?*

YesNo
Have you ever had any STI/STDs?*

YesNo
Have you ever had syphilis or gonorrhea?*

YesNo
Have you ever had hepatitis B or C?*

YesNo
Have you ever had a blood transfusion?*

YesNo
Have you ever been rejected for a blood transfusion?*

YesNo
Do you or any of your family members have a history of easily bruising or bleeding?*

YesNo
Have you ever had serious mental health issues?*

YesNo
Have you ever been clinically diagnosed with depression or bipolar disorder?*

YesNo
Have you ever taken antidepressants or anxiolytics? Explain why.*
Do you have any allergies? If so, please specify.*
Have you undergone any cosmetic surgeries in the past year? If so, please specify the type of surgery*
Do you drink coffee? How often (daily or weekly)?*
Do you drink alcohol? How often (daily or weekly)?*
Do you smoke, vape, or use marijuana? How often (daily or weekly)?*
Does your family have twins or triplets? Please specify*
Do you or any of your family members have genetic disorders？*
Have you or any of your biological family members ever been diagnosed with cancer?(If yes, please specify the type of cancer, the family member affected, and their age at diagnosis, if known.)
Do you or any of your family members have genetic disorders？*
Do you have any direct family member with autism? please explain*
Family History
Mother - Current age*
Age at death and cause of death (if applicable)*
Health Conditions*
Height*
Eye Color*

BrownHazelGreenBlue
Natural Hair Color*

BlackBrownRedBlonde
Occupation*
Father - Current age*
Age at death and cause of death (if applicable)*
Health Conditions*
Height*
Eye Color*

BrownHazelGreenBlue
Natural Hair Color*

BlackBrownRedBlonde
Occupation*
Maternal Grandfather - Current age*
Age at death and cause of death (if applicable)*
Health Conditions*
Height*
Eye Color*

BrownHazelGreenBlue
Natural Hair Color*

BlackBrownRedBlonde
Occupation*
Maternal Grandmother - Current age*
Age at death and cause of death (if applicable)*
Health Conditions*
Height*
Eye Color*

BrownHazelGreenBlue
Natural Hair Color*

BlackBrownRedBlonde
Occupation*
Paternal Grandfather - Current age*
Age at death and cause of death (if applicable)*
Health Conditions*
Height*
Eye Color*

BrownHazelGreenBlue
Natural Hair Color*

BlackBrownRedBlonde
Occupation*
Paternal Grandmother - Current age*
Age at death and cause of death (if applicable)*
Health Conditions*
Height*
Eye Color*

BrownHazelGreenBlue
Natural Hair Color*

BlackBrownRedBlonde
Occupation*
Do you have siblings?*

YesNo
How many siblings do you have in total? Please specify how many are brothers and how many are sisters.*
Read carefully: Photo Requirements for Egg Donor Application to complete your egg donor application, you must submit 10–20 photos from different stages of your life, including: Baby pictures (required)Teenage pictures (required) Recent pictures (required)A full-body photo (required)All photos must have good lighting and no group pictures, as they help intended parents in making their decision. Bikini and lingerie photos are not permitted. This is a mandatory requirement, and applications that do not meet these guidelines may be rejected.
Photo Uploads

MUST-HAVE PHOTO REQUIREMENTS: Please upload 15-20 clear, high-quality photos. A natural smile and modest, polished attire work best. Vibrant colors and your natural hair color will help highlight your true self. Feel free to share photos of your interests and hobbies! AVOID THESE COMMON MISTAKES: Avoid blurry, low-resolution images, exaggerated expressions, or bathroom mirror selfies. Ensure good lighting, and limit editing. No bikini pictures, please.
Current Pictures*

Cancelof
Baby Photos*

Cancelof
I certify that all the information provided in this application is true, complete, and accurate to the best of my knowledge. I understand that providing false or misleading information may result in my disqualification from the egg donation program.*
Confidentiality First:Your privacy matters to us. Everything you share in this form is 100% confidential and will never be shared with anyone outside of our agency without your permission. We’re here to protect you and guide you through this process with care and respect.*
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Egg Donor Questionnaire

Personal

Education

OB-GYN

Medical History

Family History

Photo Uploads