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?
Name of Referring Egg Donor or Recruiter

First NameLast Name
Personal
Please select your zodiac sign (based on your date of birth):
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?
Are you adopted?
Please indicate your religion
Height
Weight
Height
Weight
Weight
Eye Color
Natural Hair Color
Hair Texture
Complexion
Do you have Freckles?
Corrective Dental?
Do you currently wear glasses?
Marital Status
Are you a US Citizen or have permeant residency?
If no, what type of visa are you on?
Where were you born?
What amount are you seeking as compensation?
Is your family supportive of your decision to pursue egg donation?
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, what message 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?
Please list any additional courses, certifications, or training completed outside of a degree program below:
If in US, College Grade Point Average (GPA)

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

Rows	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.

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?
Have you had any piercings in the past 12 months?
Have you ever been diagnosed with cancer?
Do you have any birth defects?
Have you ever had any STI/STDs?
Have you ever had syphilis or gonorrhea?
Have you ever had hepatitis B or C?
Have you ever had a blood transfusion?
Have you ever been rejected for a blood transfusion?
Do you or any of your family members have a history of easily bruising or bleeding?
Have you ever had serious mental health issues?
Have you ever been clinically diagnosed with depression or bipolar disorder?
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 history of autism or Down syndrome? If yes, please provide details.
Family History
Mother - Current age
Age at death and cause of death (if applicable)
Health Conditions
Height
Eye Color
Natural Hair Color
Occupation
Father - Current age
Age at death and cause of death (if applicable)
Health Conditions
Height
Eye Color
Natural Hair Color
Occupation
Maternal Grandfather - Current age (enter 0 if deceased)
Age at death and cause of death (if applicable)
Health Conditions
Height
Eye Color
Natural Hair Color
Occupation
Maternal Grandmother - Current age (enter 0 if deceased)
Age at death and cause of death (if applicable)
Health Conditions
Height
Eye Color
Natural Hair Color
Occupation
Paternal Grandfather - Current age (enter 0 if deceased)
Age at death and cause of death (if applicable)
Health Conditions
Height
Eye Color
Natural Hair Color
Occupation
Paternal Grandmother - Current age(enter 0 if deceased)
Age at death and cause of death (if applicable)
Health Conditions
Height
Eye Color
Natural Hair Color
Occupation
Do you have siblings?
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.
Please upload Baby Photos (infant/early childhood)
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Please upload Teenage Photos (ages 13–18)
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Current Photos (taken within the last 6–12 months)
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All applicants are required to submit a short 10–20 second video within 3 days of applying by email to hello@eggvise.com. In the video, please speak about your hobbies and share a positive experience. Do not include your name, address, or school name.
Communication is essential. All emails, texts, and calls must be responded to within 12 hours. Failure to meet this requirement may result in withdrawal from our database.
Once approved, you are required to schedule a call with our coordinator as part of the onboarding process to review next steps and address any questions you may have.
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 and Intended parents without your permission. We’re here to protect you and guide you through this process with care and respect.
Signature
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Egg Donor Questionnaire

Personal

Education

OB-GYN

Medical History

Family History

Photo Uploads

Please upload Baby Photos (infant/early childhood)

Please upload Teenage Photos (ages 13–18)

Current Photos (taken within the last 6–12 months)