Risk Factor Questionnaire
Known Egg Donor
First Name Only
Please mark 'Yes' or 'No' on each question.
Have you ever been in a same sex relationship?
Have you ever used injectable drugs (a needle) for non-medical use including steroids not prescribed by a doctor, intravenous, intramuscular, and subcutaneous?
Do you have or have you had sexual contact with a person who has hemophilia or a related clotting disorder or has received human-derived clotting factor concentrates?
In the past 12 months have you had sex with any person described in the previous questions or with any person known or suspected to have HIV infection, clinically active hepatitis B infections, or hepatitis C infection?
Have you had close contact within 12 months preceding donation with another person having clinically active viral hepatitis (i.e., living in the same household, where sharing of kitchen and bathroom facilities occurs regularly)?
Have you had any accidental contact with another person’s blood/body fluids or have you had an accidental needle stick in the past 12 months?
Have you had any contact to blood that is known or suspected to be infected with HIV, Hepatitis B and/or Hepatitis C virus?
Have you ever been incarcerated for more than 72 consecutive hours during the previous 12 months?
Have you ever had sex with someone who has been in prison?
Have you or a family member had Creutzfeldt-Jakob disease or been told that you are at increased risk for it?
Within the past 12 months have you undergone ear or body piercing, tattooing, or acupuncture in which shared instruments are known to have been used?
Have you been treated for syphilis or gonorrhea within the last 12 months?
Have you ever had herpes?
Have you been diagnosed with or tested for sepsis?
Were you a member of the US military, civilian military, employee or a dependent of a member of the military stationed in Belgium, the Netherlands, Germany, Spain, Portugal, Turkey, Italy, or Greece between 1980-1996?
Were you born in or have lived in any of the following countries since 1977: Cameroon, Central African Republic, Chad, Congo, Equatorial Guinea, Gabon, Niger, or Nigeria?
Were you given a blood transfusion or any medical treatment with a product made from blood while you were there?
Have you ever had sexual contact with anyone who was born or lived in any African country since 1977?
Have you traveled to Europe within the past 6 months?
Since 1980, have you spent time that adds up to 5 years in Europe?
Have you visited or lived in the United Kingdom for three months or more from 1980-1996? (England, Scotland, Wales, Ireland, Isle of Man, Channel Islands, Gibraltar, Falkland Islands)?
Are you a citizen of the United States?
Have you had any recent surgeries?
Do you carry current medical insurance?
Have you been diagnosed with Hepatitis A or received gamma globulin shots for Hepatitis A exposure?
Were you ever told you had viral hepatitis after the age of 11 years old?
Have you received a recent Small Pox vaccination?
If yes, did the scab separate spontaneously or physician evaluated that the scab at the vaccine site was gone?
Was the scab evaluated 21 days after the vaccine?
Have you had any skin rashes or skin sores since your vaccination or contact with the person who received the vaccination?
Have you received Human Pituitary Growth Hormone or received a dura mater (brain covering) graft?
In the past 12 months have you received a rabies shot?
Have you ever injected Bovine (beef) insulin?
Have you been suspected to have SARS or have you been exposed or treated for SARS within the previous 28 days?
In the past 14 days have you cared for, lived with, or had direct contact with body fluids of someone with SARS or suspected SARS?
Have you traveled to or resided in areas affected by SARS within the previous 14 days?
Have you traveled to or resided in areas affected by ZIKA within the previous year?
Have you had sex with anyone who has traveled to or resided in areas affected by ZIKA within the previous year?
Have you had any recent vaccinations?
Have you or your sexual partner and/or any other member of your household ever received a transplant or other medical procedure that involved being exposed to live cells, tissues, or organs from an animal?
Should be Empty: