EGG RECIPIENT APPLICATION

EGG RECIPIENT APPLICATION
How did you hear about us?*
If you were referred, please provide a name if possible.
FEMALE PARTNER INFORMATION
MALE PARTNER INFORMATION
Female Partner Name*

First NameLast Name
Male Partner Name*

First NameLast Name
Female Partner Date of Birth*

MonthDayYear
Male Partner Date of Birth*

MonthDayYear
Female Partner Contact Number*
Male Partner Contact Number*
Female Partner Email*
Male Partner Email*
Female Partner Social Security Number*
Male Partner Social Seurityc Number*
Female Partner Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Male Partner Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Female Partner Employer or School*
Male Partner Employer or School*
Female Partner Work Number*
Male Partner Work Number*
Female Partner: What is your preferred method of contact?*
Male Partner: What is your preferred method of contact?*
Female Partner Occupation or Major/Minor*
Male Partner Occupation or Major/Minor*
Female Partner Years of Education / Degree*
Male Partner Years of Education / Degree*
FEMALE PARTNER: PHYSICAL CHARACTERISTICS
MALE PARTNER: PHYSICAL CHARACTERISTICS
Female Partner: Height*
Male Partner: Height*
Female Partner: Weight*
Male Partner: Weight*
Female Partner: What is your natural hair color?*

BlackLight BrownDark / Medium BrownAuburn (Reddish-Brown)Strawberry Blonde (Reddish-Blonde)Dark / Medium BlondeLight BlondePlatinum Blonde (Very Light Blonde)
Male Partner: What is your natural hair color?*

BlackLight BrownDark / Medium BrownAuburn (Reddish-Brown)Strawberry Blonde (Reddish-Blonde)Dark / Medium BlondeLight BlondePlatinum Blonde (Very Light Blonde)
Female Partner: What is your hair texture?*

Straight HairWavy HairCurly HairCoily Hair
Male Partner: What is your hair texture?*

Straight HairWavy HairCurly HairCoily Hair
Female Partner: What is your eye color?*

BrownHazelAmberGreenBlueGray
Nale Partner: What is your eye color?*

BrownHazelAmberGreenBlueGray
Female Partner: Race*

WhiteAsianBlack or African AmericanAmerican Indian or Alaska NativeNative Hawaiian or Other Pacific IslanderMixed / Multiracial (two or more races)
Male Partner: Race*

WhiteAsianBlack or African AmericanAmerican Indian or Alaska NativeNative Hawaiian or Other Pacific IslanderMixed / Multiracial (two or more races)
Female: List the COUNTRY of most of your ancestors and yourself.*
Male: List the COUNTRY of most of your ancestors and yourself.*
Female: List the STATE of most of your ancestors and yourself.*
Male: List the STATE of most of your ancestors and yourself.*
Female: List the COUNTY of most of your ancestors and yourself.*
Male: List the COUNTY of most of your ancestors and yourself.*
Female Partner: Blood Type*

AOBABUnknown
Female Partner: Blood Type*

AOBABUnknown
Female Partner: Blood Type Rh Factor*

Positive (+)Negative (-)Unknows
Male Partner: Blood Type Rh Factor*

Positive (+)Negative (-)Unknown
Female Partner: Please upload a picture.

Cancelof
Male Partner: Please upload a picture.

Cancelof
CHARACTERISTICS OF RECIPIENTS' DESIRE OF THEIR DONOR

To facilitate matching your egg donor, please indicate the importance of the characteristics below on a scale of 1-5 stars, with one star being the least important and five stars being the most important.
Importance of Eye Color*
Importance of Hair Color*
Importance of Height*
Importance of Weight*
Importance of Education*
Importance of Blood Type*
If there is a high importance of weight and or height, please specify range. Also add any other comments on any of the above, or add to your specifications.*
Preferences for Donor's Ancestry*

African AncestryAsian AncestryEuropean AncestryMiddle Eastern and North African AncestryHispanic / Latino AncestryIndigenous and Pacific Islander AncestryMixed and Multiracial Ancestry
Preferences for Donor's Skin Tone*

FairOliveMediumDark
Preferences for Donor's Interests*

SportsScienceMusicVolunteer Work
Please specify any other preferences for donor if not listed above.
FEMALE PARTNER MEDICAL INFORMATION
MALE PARTNER MEDICAL INFORMATION
Female: Are there any known genetic or birth defects in your family?*

NoYes
Male: Are there any known genetic or birth defects in your family?*

NoYes
Female: If there are known genetic or birth defects, please explain here.
Male: If there are known genetic or birth defects, please explain here.
Female: Have you ever been tested as a carrier of Tay Sach's Disease?*

CarrierNot a CarrierDon't Know
Male: Have you ever been tested as a carrier of Tay Sach's Disease?*

CarrierNot a CarrierDon't Know
FEMALE: Have you ever been tested as a carrier of Sickle Cell Disease?*

CarrierNot a CarrierDon't Know
MALE: Have you ever been tested as a carrier of Sickle Cell Disease?*

CarrierNot a CarrierDon't Know
FEMALE: Do you have any Jewish Relatives?*

YesNo
MALE: Do you have any Jewish Relatives?*

YesNo
FEMALE: Do you have any Black Relatives?*

YesNo
MALE: Do you have any Black Relatives?*

YesNo
FEMALE: Do you have any current health problems?*

YesNo
MALE: Do you have any current health problems?*

YesNo
FEMALE: If you have any current health problems, please explain here.
MALE: If you have any current health problems, please explain here.
FEMALE: If you were born with any health problems such as heart defect, cleft lip or palate, club feet etc., please explain and give age of diagnosis.
MALE: If you were born with any health problems such as heart defect, cleft lip or palate, club feet etc., please explain and give age of diagnosis.
FEMALE: How much alcohol do you consume a week?*
MALE: How much alcohol do you consume a week?*
FEMALE: Have you shared needles or used intravenous (street) drugs?*

YesNo
MALE: Have you shared needles or used intravenous (street) drugs?*

YesNo
FEMALE: Have you ever had a blood transfusion?*

YesNo
MALE: Have you ever had a blood transfusion?*

YesNo
FEMALE: Have you ever had a sexually transmitted disease (STD)?*

YesNo
MALE: Have you ever had a sexually transmitted disease (STD)?*

YesNo
FEMALE: If you have ever had an STD, please explain diagnosis, when and treatment.
MALE: If you have ever had an STD, please explain diagnosis, when and treatment.
FEMALE: If you have ever been hospitalized, please give dates and reason.
MALE: If you have ever been hospitalized, please give dates and reason.
FEMALE PARTNER: FATHER'S FAMILY
MALE PARTNER: FATHER'S FAMILY
FEMALE PARTNER: FATHER'S FAMILY RACE & ANCESTRY*

Caucasian / WhiteAsianAmerican Indian or Alaska NativeBlack / African AmericanNative Hawaiian / Pacific IslanderMixed / Multicultural (two or more races)African AncestryAsian AncestryEuropean AncestryMiddle Eastern & North African AncestryHispanic/Latino AncestryIndigenous & Pacific Islander AncestryMixed/Multiracial Ancestry (two or more Ancestry)
MALE PARTNER: FATHER'S FAMILY RACE & ANCESTRY*

Caucasian / WhiteAsianAmerican Indian or Alaska NativeBlack / African AmericanNative Hawaiian / Pacific IslanderMixed / Multicultural (two or more races)African AncestryAsian AncestryEuropean AncestryMiddle Eastern & North African AncestryHispanic/Latino AncestryIndigenous & Pacific Islander AncestryMixed/Multiracial Ancestry (two or more Ancestry)
FEMALE PARTNER: FATHER'S FAMILY - CHOOSE ALL THAT APPLY*

DimplesFrecklesCleft LipLight Skin ToneMedium Skin ToneDark Skin ToneBrown EyesHazel EyesAmber EyesGreen EyesBlue EyesBlack HairBrown HairAuburn / Red HairDark Blonde HairLight Blonde HairStraight HairWavy HairCurly HairCoily Hair
MALE PARTNER: FATHER'S FAMILY - CHOOSE ALL THAT APPLY*

DimplesFrecklesCleft LipLight Skin ToneMedium Skin ToneDark Skin ToneBrown EyesHazel EyesAmber EyesGreen EyesBlue EyesBlack HairBrown HairAuburn / Red HairDark Blonde HairLight Blonde HairStraight HairWavy HairCurly HairCoily Hair
FEMALE PARTNER: FATHER'S FAMILY - CHOOSE ALL THAT APPLY*

Father is living and healthyFather is living and unhealthyFather is living, but his health is unknownFather is deceasedFather's father is living and healthyFather's father is living and unhealthyFather's father is living, but his health is unknownFather's father is deceasedFather's mother is living and healthyFather's mother is living and unhealthyFather's mother is living, but his health is unknownFather's mother is deceased
MALE PARTNER: FATHER'S FAMILY - CHOOSE ALL THAT APPLY*

Father is living and healthyFather is living and unhealthyFather is living, but his health is unknownFather is deceasedFather's father is living and healthyFather's father is living and unhealthyFather's father is living, but his health is unknownFather's father is deceasedFather's mother is living and healthyFather's mother is living and unhealthyFather's mother is living, but his health is unknownFather's mother is deceased
FEMALE PARTNER: FATHER: If deceased, note his age of death, cause of death. If living, note his year of birth.
MALE PARTNER: FATHER: If deceased, note his age of death, cause of death. If living, note his year of birth.
FEMALE PARTNER: FATHER'S FATHER: If deceased, note his age of death, cause of death. If living, note his year of birth.
MALE PARTNER: FATHER'S FATHER: If deceased, note his age of death, cause of death. If living, note his year of birth.
FEMALE PARTNER: FATHER'S MOTHER: If deceased, note her age of death, cause of death. If living, note her year of birth.
MALE PARTNER: FATHER'S MOTHER: If deceased, note her age of death, cause of death. If living, note her year of birth.
FEMALE PARTNER: MOTHER'S FAMILY
MALE PARTNER: MOTHER'S FAMILY
FEMALE PARTNER'S MOTHER'S FAMILY RACE & ANCESTRY*

Caucasian / WhiteAsianAmerican Indian or Alaska NativeBlack / African AmericanNative Hawaiian / Pacific IslanderMixed / Multicultural (two or more races)African AncestryAsian AncestryEuropean AncestryMiddle Eastern & North African AncestryHispanic/Latino AncestryIndigenous & Pacific Islander AncestryMixed/Multiracial Ancestry (two or more Ancestry)
MALE PARTNER'S MOTHER'S FAMILY RACE & ANCESTRY*

Caucasian / WhiteAsianAmerican Indian or Alaska NativeBlack / African AmericanNative Hawaiian / Pacific IslanderMixed / Multicultural (two or more races)African AncestryAsian AncestryEuropean AncestryMiddle Eastern & North African AncestryHispanic/Latino AncestryIndigenous & Pacific Islander AncestryMixed/Multiracial Ancestry (two or more Ancestry)
FEMALE PARTNER'S MOTHER'S FAMILY - CHOOSE ALL THAT APPLY*

DimplesFrecklesCleft LipLight Skin ToneMedium Skin ToneDark Skin ToneBrown EyesHazel EyesAmber EyesGreen EyesBlue EyesBlack HairBrown HairAuburn / Red HairDark Blonde HairLight Blonde HairStraight HairWavy HairCurly HairCoily Hair
MALE PARTNER'S MOTHER'S FAMILY - CHOOSE ALL THAT APPLY*

DimplesFrecklesCleft LipLight Skin ToneMedium Skin ToneDark Skin ToneBrown EyesHazel EyesAmber EyesGreen EyesBlue EyesBlack HairBrown HairAuburn / Red HairDark Blonde HairLight Blonde HairStraight HairWavy HairCurly HairCoily Hair
FEMALE PARTNER'S MOTHER'S FAMILY - CHOOSE ALL THAT APPLY*

Mother is living and healthyMother is living and unhealthyMother is living, but his health is unknownMother is deceasedMother's father is living and healthyMother's father is living and unhealthyMother's father is living, but his health is unknownMother's father is deceasedMother's mother is living and healthyMother's mother is living and unhealthyMother's mother is living, but his health is unknownMother's mother is deceased
MALE PARTNER'S MOTHER'S FAMILY - CHOOSE ALL THAT APPLY*

Mother is living and healthyMother is living and unhealthyMother is living, but his health is unknownMother is deceasedMother's father is living and healthyMother's father is living and unhealthyMother's father is living, but his health is unknownMother's father is deceasedMother's mother is living and healthyMother's mother is living and unhealthyMother's mother is living, but his health is unknownMother's mother is deceased
FEMALE PARTNER: Did your mother take DES when she was pregnancy with you?*

NoYesUnknown
MALE PARTNER: Did your mother take DES when she was pregnancy with you?*

NoYesUnknown
FEMALE PARTNER'S MOTHER: If deceased, note her age of death, cause of death. If living, note her year of birth.
MALE PARTNER'S MOTHER: If deceased, note her age of death, cause of death. If living, note her year of birth.
FEMALE PARTNER: MOTHER'S MOTHER: If deceased, note her age of death, cause of death. If living, note her year of birth.
FEMALE PARTNER: MOTHER'S MOTHER: If deceased, note her age of death, cause of death. If living, note her year of birth.
FEMALE PARTNER: MOTHER'S FATHER: If deceased, note his age of death, cause of death. If living, note his year of birth.
FEMALE PARTNER: MOTHER'S FATHER: If deceased, note his age of death, cause of death. If living, note his year of birth.
FEMALE PARTNER'S CHILDREN (IF ANY)
FEMALE PARTNER'S CHILDREN (IF ANY)
FEMALE PARTNER: List children's gender, year of birth, health status, eye color, hair type and hair color. If deceased, please list age and cause of death.
MALE PARTNER: List children's gender, year of birth, health status, eye color, hair type and hair color. If deceased, please list age and cause of death.
FEMALE PARTNER: BLOOD RELATIVES
MALE PARTNER: BLOOD RELATIVES
FEMALE PARTNER: List siblings' gender, year of birth, and health status. If deceased, please list age and cause of death.
MALE PARTNER: List siblings' gender, year of birth, and health status. If deceased, please list age and cause of death.
FEMALE PARTNER MOTHER'S SIDE: List aunts' and uncles' gender, year of birth, and health status. If deceased, please list age and cause of death.
MALE PARTNER MOTHER'S SIDE: List aunts' and uncles' gender, year of birth, and health status. If deceased, please list age and cause of death.
FEMALE PARTNER FATHER'S SIDE: List aunts' and uncles' gender, year of birth, and health status. If deceased, please list age and cause of death.
MALE PARTNER FATHER'S SIDE: List aunts' and uncles' gender, year of birth, and health status. If deceased, please list age and cause of death.
MEDIAL HISTORY OF FEMALE AND MALE PARTNERS AND THEIR BLOOD RELATIVES

Please complete the charts to the best of your knowledge. Providing accurate and thorough information is in your best interest. The listed medical conditions apply only to your blood relatives (parents, grandparents, aunts, uncles, cousins, siblings, and children). If you're unsure about an answer, leave it blank—do not guess. If none of the conditions apply, please select "No One."

Maternal – Related to the mother's side of the family (e.g., maternal grandmother = your mother's mother).
Paternal – Related to the father's side of the family (e.g., paternal uncle = your father's brother).

FEMALE PARTNER: Blood Anomalies*

	No One	Self	Mother	Father	Brothers	Sisters	Daughters	Sons	Maternal Aunts	Maternal Uncles	Paternal Aunts	Paternal Uncles	Maternal Grandma	Maternal Grandpa	Paternal Grandma	Paternal Grandpa
Anemia
Sickle-cell
Hemophilia
HIV
Thalassemia
Other Blood Issues

MALE PARTNER: Blood Anomalies*

	No One	Self	Mother	Father	Brothers	Sisters	Daughters	Sons	Maternal Aunts	Maternal Uncles	Paternal Aunts	Paternal Uncles	Maternal Grandma	Maternal Grandpa	Paternal Grandma	Paternal Grandpa
Anemia
Sickle-cell
Hemophilia
HIV
Thalassemia
Other Blood Issues

FEMALE PARTNER: Congenital Anomalies*

	No One	Self	Mother	Father	Brothers	Sisters	Daughters	Sons	Maternal Aunts	Maternal Uncles	Paternal Aunts	Paternal Uncles	Maternal Grandma	Maternal Grandpa	Paternal Grandma	Paternal Grandpa
Cleft Lip/Palate
Hip Problems
Club Feet
Cri Du Chat
Trisomy 18
Trisomy 13
Fragile X
Other Congenital Anomalies

MALE PARTNER: Congenital Anomalies*

	No One	Self	Mother	Father	Brothers	Sisters	Daughters	Sons	Maternal Aunts	Maternal Uncles	Paternal Aunts	Paternal Uncles	Maternal Grandma	Maternal Grandpa	Paternal Grandma	Paternal Grandpa
Cleft Lip/Palate
Hip Problems
Club Feet
Cri Du Chat
Trisomy 18
Trisomy 13
Fragile X
Other Congenital Anomalies

FEMALE PARTNER: Gastro-Intestinal Anomalies*

	No One	Self	Mother	Father	Brothers	Sisters	Daughters	Sons	Maternal Aunts	Maternal Uncles	Paternal Aunts	Paternal Uncles	Maternal Grandma	Maternal Grandpa	Paternal Grandma	Paternal Grandpa
Ulcers of Stomach
Gall Stones
Hepatitis A (Infectious)
Hepatitis B (Serum)
Development Disorders of Stomach and Intestine
Pyloric Stenosis
Rectal Disorder
Other Gastro-Intestinal Issues

MALE PARTNER: Gastro-Intestinal Anomalies*

	No One	Self	Mother	Father	Brothers	Sisters	Daughters	Sons	Maternal Aunts	Maternal Uncles	Paternal Aunts	Paternal Uncles	Maternal Grandma	Maternal Grandpa	Paternal Grandma	Paternal Grandpa
Ulcers of Stomach
Gall Stones
Hepatitis A (Infectious)
Hepatitis B (Serum)
Development Disorders of Stomach and Intestine
Pyloric Stenosis
Rectal Disorder
Other Gastro-Intestinal Issues

FEMALE PARTNER: Genital Reproductive Anomalies*

	No One	Self	Mother	Father	Brothers	Sisters	Daughters	Sons	Maternal Aunts	Maternal Uncles	Paternal Aunts	Paternal Uncles	Maternal Grandpa	Maternal Grandpa	Paternal Grandma	Paternal Grandpa
Undescended Testicle
Hermaphroditism / Ambiguous Genitals
Hypospadias
Lumps or Cysts in Breasts
Breast Surgery
Two or More Miscarriages
Stillborn
Death of Newborn Infant
Neonatal Jaundice
Other Genital Reproductive Issues

MALE PARTNER: Genital Reproductive Anomalies*

	No One	Self	Mother	Father	Brothers	Sisters	Daughters	Sons	Maternal Aunts	Maternal Uncles	Paternal Aunts	Paternal Uncles	Maternal Grandpa	Maternal Grandpa	Paternal Grandma	Paternal Grandpa
Undescended Testicle
Hermaphroditism / Ambiguous Genitals
Hypospadias
Lumps or Cysts in Breasts
Breast Surgery
Two or More Miscarriages
Stillborn
Death of Newborn Infant
Neonatal Jaundice
Other Genital Reproductive Issues

FEMALE PARTNER: Heart Anomalies*

	No One	Self	Mother	Father	Brothers	Sisters	Daughters	Sons	Maternal Aunts	Maternal Uncles	Paternal Aunts	Paternal Uncles	Maternal Grandma	Maternal Grandpa	Paternal Grandma	Paternal Grandpa
Stroke
Heart Attack
Heart Disease
Hardening of Arteries
High Blood Pressure
High Cholesterol
Other Heart Issues

MALE PARTNER: Heart Anomalies*

	No One	Self	Mother	Father	Brothers	Sisters	Daughters	Sons	Maternal Aunts	Maternal Uncles	Paternal Aunts	Paternal Uncles	Maternal Grandma	Maternal Grandpa	Paternal Grandma	Paternal Grandpa
Stroke
Heart Attack
Heart Disease
Hardening of Arteries
High Blood Pressure
High Cholesterol
Other Heart Issues

FEMALE PARTNER: Mental Anomalies*

	No One	Self	Mother	Father	Brothers	Sisters	Daughters	Sons	Maternal Aunts	Maternal Uncles	Paternal Aunts	Paternal Uncles	Maternal Grandma	Maternal Grandpa	Paternal Grandma	Paternal Grandpa
Schizophrenia
Manic Depression or Bipolar Disorder
Anxiety or Panic Attacks
Mild Depression
Other Mental Health Issues

MALE PARTNER: Mental Anomalies*

	No One	Self	Mother	Father	Brothers	Sisters	Daughters	Sons	Maternal Aunts	Maternal Uncles	Paternal Aunts	Paternal Uncles	Maternal Grandma	Maternal Grandpa	Paternal Grandma	Paternal Grandpa
Schizophrenia
Manic Depression or Bipolar Disorder
Anxiety or Panic Attacks
Mild Depression
Other Mental Health Issues

FEMALE PARTNER: Metabolic / Endocrine Anomalies*

	No One	Self	Mother	Father	Brothers	Sisters	Daughters	Sons	Maternal Aunts	Maternal Uncles	Paternal Aunts	Paternal Uncles	Maternal Grandma	Maternal Grandpa	Paternal Grandma	Paternal Grandpa
Diabetes: Type 1 or 2
Hypoglycemia
Thyroid Cancer
Thyroid Disease
Goiter
Adrenal Dysfunction
Hyperactivity
Other Metabolic or Endocrine Issues

MALE PARTNER: Metabolic / Endocrine Anomalies*

	No One	Self	Mother	Father	Brothers	Sisters	Daughters	Sons	Maternal Aunts	Maternal Uncles	Paternal Aunts	Paternal Uncles	Maternal Grandma	Maternal Grandpa	Paternal Grandma	Paternal Grandpa
Diabetes: Type 1 or 2
Hypoglycemia
Thyroid Cancer
Thyroid Disease
Goiter
Adrenal Dysfunction
Hyperactivity
Other Metabolic or Endocrine Issues

FEMALE PARTNER: Muscle, Bones, or Joint Anomalies*

	No One	Self	Mother	Father	Brothers	Sisters	Daughters	Sons	Maternal Aunts	Maternal Uncles	Paternal Aunts	Paternal Uncles	Maternal Grandma	Maternal Grandpa	Paternal Grandma	Paternal Grandpa
Muscular Dystrophy
Loss of Muscle Disease
Loss of Muscle Coordination
Lupus
Osteoporosis
Dwarfism
Arthiritis
Gout
Myasthenia Gravis
Other Muscle, Bone or Joint Issues

MALE PARTNER: Muscle, Bones, or Joint Anomalies*

	No One	Self	Mother	Father	Brothers	Sisters	Daughters	Sons	Maternal Aunts	Maternal Uncles	Paternal Aunts	Paternal Uncles	Maternal Grandma	Maternal Grandpa	Paternal Grandma	Paternal Grandpa
Muscular Dystrophy
Loss of Muscle Disease
Loss of Muscle Coordination
Lupus
Osteoporosis
Dwarfism
Arthiritis
Gout
Myasthenia Gravis
Other Muscle, Bone or Joint Issues

FEMALE PARTNER: Neurological Anomalies*

	No One	Self	Mother	Father	Brothers	Sisters	Daughters	Sons	Maternal Aunts	Maternal Uncles	Paternal Aunts	Paternal Uncles	Maternal Grandma	Maternal Grandpa	Paternal Grandma	Paternal Grandpa
Migraines
Mental Retardation
Downs Syndrome
Alzheimer's Syndrome
Senility Before Age 50
Multiple Sclerosis
Cerebral Palsy
Epilepsy / Seizures
Hydrocephalus
Spina Bifida / Neural Tubal Defect
Huntington's Disease
Gauchers Disease
Wilson's Disease
Parkinson's Disease
Paraplegia
Tourettes Syndrome
Scoliosis
Tay-Sachs Disease
Other Neurological Issues

MALE PARTNER: Neurological Anomalies*

	No One	Self	Mother	Father	Brothers	Sisters	Daughters	Sons	Maternal Aunts	Maternal Uncles	Paternal Aunts	Paternal Uncles	Maternal Grandma	Maternal Grandpa	Paternal Grandma	Paternal Grandpa
Migraines
Mental Retardation
Downs Syndrome
Alzheimer's Syndrome
Senility Before Age 50
Multiple Sclerosis
Cerebral Palsy
Epilepsy / Seizures
Hydrocephalus
Spina Bifida / Neural Tubal Defect
Huntington's Disease
Gauchers Disease
Wilson's Disease
Parkinson's Disease
Paraplegia
Tourettes Syndrome
Scoliosis
Tay-Sachs Disease
Other Neurological Issues

FEMALE PARTNER: Respiratory Anomalies*

	No One	Self	Mother	Father	Brothers	Sisters	Daughters	Sons	Maternal Aunts	Maternal Uncles	Paternal Aunts	Paternal Uncles	Maternal Grandma	Maternal Grandpa	Paternal Grandma	Paternal Grandpa
Allergies
Asthma
Emphysema
Tuberculosis
Pneumonia
Cystic Fibrosis
Other Respiratory (Lung) Disease

MALE PARTNER: Respiratory Anomalies*

	No One	Self	Mother	Father	Brothers	Sisters	Daughters	Sons	Maternal Aunts	Maternal Uncles	Paternal Aunts	Paternal Uncles	Maternal Grandma	Maternal Grandpa	Paternal Grandma	Paternal Grandpa
Allergies
Asthma
Emphysema
Tuberculosis
Pneumonia
Cystic Fibrosis
Other Respiratory (Lung) Disease

FEMALE PARTNER: Sight, Smell, or Sound Anomalies*

	No One	Self	Mother	Father	Brothers	Sisters	Daughters	Sons	Maternal Aunts	Maternal Uncles	Paternal Aunts	Paternal Uncles	Maternal Grandma	Maternal Grandpa	Paternal Grandma	Paternal Grandpa
Deafness Before Age 60
Ear Deformity
Cataracts Before Age 50
Blindness
Color Blindness
Glaucoma
Deviated Septum
Other Sight, Smell or Sound Issues

MALE PARTNER: Sight, Smell, or Sound Anomalies*

	No One	Self	Mother	Father	Brothers	Sisters	Daughters	Sons	Maternal Aunts	Maternal Uncles	Paternal Aunts	Paternal Uncles	Maternal Grandma	Maternal Grandpa	Paternal Grandma	Paternal Grandpa
Deafness Before Age 60
Ear Deformity
Cataracts Before Age 50
Blindness
Color Blindness
Glaucoma
Deviated Septum
Other Sight, Smell or Sound Issues

FEMALE PARTNER: Skin Anomalies*

	No One	Self	Mother	Father	Brothers	Sisters	Daughters	Sons	Maternal Aunts	Maternal Uncles	Paternal Aunts	Paternal Uncles	Maternal Grandma	Maternal Grandpa	Paternal Grandma	Paternal Grandpa
Acne
Eczema
Pigmentation Disorder
Neurofibro-matosis
Other Skin Issues

MALE PARTNER: Skin Anomalies*

	No One	Self	Mother	Father	Brothers	Sisters	Daughters	Sons	Maternal Aunts	Maternal Uncles	Paternal Aunts	Paternal Uncles	Maternal Grandma	Maternal Grandpa	Paternal Grandma	Paternal Grandpa
Acne
Eczema
Pigmentation Disorder
Neurofibro-matosis
Other Skin Issues

FEMALE PARTNER: Chromosomal Abnormalities*

	No One	Self	Mother	Father	Brothers	Sisters	Daughters	Sons	Maternal Aunts	Maternal Uncles	Paternal Aunts	Paternal Uncles	Maternal Grandma	Maternal Grandpa	Paternal Grandma	Paternal Grandpa
Turner Syndrome
Kleinfelter Syndrome
Other Chromosomal Abnormalities

MALE PARTNER: Chromosomal Abnormalities*

	No One	Self	Mother	Father	Brothers	Sisters	Daughters	Sons	Maternal Aunts	Maternal Uncles	Paternal Aunts	Paternal Uncles	Maternal Grandma	Maternal Grandpa	Paternal Grandma	Paternal Grandpa
Turner Syndrome
Kleinfelter Syndrome
Other Chromosomal Abnormalities

FEMALE PARTNER: Urinary Anomalies*

	No One	Self	Mother	Father	Brothers	Sisters	Daughters	Sons	Maternal Aunts	Maternal Uncles	Paternal Aunts	Paternal Uncles	Maternal Grandma	Maternal Grandpa	Paternal Grandma	Paternal Grandpa
Kidney Disease
Other Urinary Issues

MALE PARTNER: Urinary Anomalies*

	No One	Self	Mother	Father	Brothers	Sisters	Daughters	Sons	Maternal Aunts	Maternal Uncles	Paternal Aunts	Paternal Uncles	Maternal Grandma	Maternal Grandpa	Paternal Grandma	Paternal Grandpa
Kidney Disease
Other Urinary Issues

FEMALE PARTNER: Cancer History*

	No One	Self	Mother	Father	Brothers	Sisters	Daughters	Sons	Maternal Aunts	Maternal Uncles	Paternal Aunts	Paternal Uncles	Maternal Grandma	Maternal Grandpa	Paternal Grandma	Paternal Grandpa
Breast Cancer
Leukemia
Lymphoma
Myeloma
Lung Cancer
Stomach Cancer
Colon Cancer
Pancreatic Cancer
Liver Cancer
Skin Cancer
Prostate Cancer
Brain Cancer
Testicular Cancer
Ovarian Cancer
Cervical Cancer
Uterine Cancer
Other Cancers

MALE PARTNER: Cancer History*

	No One	Self	Mother	Father	Brothers	Sisters	Daughters	Sons	Maternal Aunts	Maternal Uncles	Paternal Aunts	Paternal Uncles	Maternal Grandma	Maternal Grandpa	Paternal Grandma	Paternal Grandpa
Breast Cancer
Leukemia
Lymphoma
Myeloma
Lung Cancer
Stomach Cancer
Colon Cancer
Pancreatic Cancer
Liver Cancer
Skin Cancer
Prostate Cancer
Brain Cancer
Testicular Cancer
Ovarian Cancer
Cervical Cancer
Uterine Cancer
Other Cancers

FEMALE PARTNER: Addictions*

	No One	Self	Mother	Father	Brothers	Sisters	Daughters	Sons	Maternal Aunts	Maternal Uncles	Paternal Aunts	Paternal Uncles	Maternal Grandma	Maternal Grandpa	Paternal Grandma	Paternal Grandpa
Alcoholism
Drug Abuse, Misuse or Addiction

MALE PARTNER: Addictions*

	No One	Self	Mother	Father	Brothers	Sisters	Daughters	Sons	Maternal Aunts	Maternal Uncles	Paternal Aunts	Paternal Uncles	Maternal Grandma	Maternal Grandpa	Paternal Grandma	Paternal Grandpa
Alcoholism
Drug Abuse, Misuse or Addiction

Are there any times that you will not be available for embryo transfer?*

NoYes
If yes, please specify.
I confirm that the information provided about myself and my blood relatives is accurate to the best of my knowledge and to the knowledge of my parents, grandparents, and other family members. I have made every effort to include all relevant details and have had the opportunity to ask any questions which have been answered to my satisfaction. This information may be part of my medical evaluation and planning. I authorize NCCRM to disclose pertinent medical, administrative, or insurance information, following applicable privacy laws and regulations
Signature of Female Partner*

Clear
Signature of Male Partner*

Clear
Date of Signature of Female Partner

MonthDayYear
Date
Date of Signature of Male Partner

MonthDayYear
Date
Should be Empty: