CONFIDENTIAL INFORMATION: (For office use only)

First Name:
Surname:
Cell phone number:
Alternative contact number:
Email address:
Address:
ID or Passport Number:
If married, does your husband approve of you donating your eggs?
Have you ever been diagnosed with infertility in the past or had difficulty conceiving for more than 1 year? If so, please provide details.
Do you know your HIV status?
Do you suffer from type 1 diabetes?
Do you take any thyroid medication? Please advise name & dosage.
Are you breastfeeding or recently had a baby?
Are you currently on any medication? If so, please provide detail.
Have you ever been under the care of a psychiatrist or psychologist? Please provide details
Are you a virgin?
How many sexual partners have you had in the last 5 years?
Have you contracted any Sexually Transmitted Infectious (STIs) from any partner?
Have you been treated for any Sexually Transmitted Infections (STIs0 in the last 5 years? (Chlamydia, gonorrhoea, HIV, Hepatitis B or C, syphilis, other)
Have you ever injected IV narcotic drugs e.g. Heroin
Are you taking any contraceptive such as pill, injection or IUD (Copper T or Mirena) to prevent pregnancy?
Have you had any termination of pregnancies before, and if so were there any medical complications?
Do you have regular or irregular menstrual periods? Do you sometimes not have periods for a few months?
Have you been diagnosed with Polysystic Ovary Syndrome before (PCOS), and if so are your periods regular or irregular?
Have you had a tubal sterilisation or had a fallopian tube removed or found to be damaged?
Have you been diagnosed with any other gynaecological conditions? Please explain
Have you had the contraceptive injection in the past 12 months? If yes when was your last injection?
Have you ever applied to be a donor with another agency and had your application declined? If yes, state the reason you were declined.
Have you donated before? If yes please be aware that we will call you for the following information regarding your previous donation/s:
Month & year you donated. The clinic at which you donated. The agency through which you donated. The number of eggs retrieved if you know this detail.
Have you read and understood the Egg Donor Information Document provided?
Do you understand and consent to having the fertility specialist check your ovaries with a standard internal vaginal scan?