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Sample Donor Profile
 
Applicant ID #   
000405
 
Personal Information:
Age:  
27
   
State of Birth:   Country of Birth:
CA     USA  
 
Partner Information:
Marital Status/History:
Separated
 
Employment History:
Current Occupation: Full Time Student
Years at current employment:  
     
If less than 2 years, provide:    
Previous Occupation:  
Years at previous employment:  
     
Current hours worked / week:  
     
 
General Information:
Would you require day care/baby sitting to attend any appointments associated with the ovum donation procedure? 
No
Are you willing to travel to California for medical appointments or procedures? Yes
     
Do you own a car? Yes
If no, do you have alternate reliable transportation?  
     
 
Personal Profile:
Religion: Catholic
Practicing?   Yes
     
Race:   Caucasian
Blood type:   AB positive
     
Height:   5 Ft   5 In
Weight:   126 Pounds
BMI:  
21
     
Body Type/Build:   Medium
     
Eye Color:   Blue
     
Natural Hair Texture:   Straight
Natural Hair Color:   Brown
     
Skin Type:   Combination
Skin Complexion:   Medium
Tanning Ability:   Tans moderately
Freckles:   Few
Freckles Location(s):   Body-Arms, Legs, Torso
     
Birth Mark(s): No
(Location/Type)
Moles/Warts: Yes
One on my neck, and one on my back.
(Location/Type)
     
Cleft Chin:
Dominant Hand:   Right
Shoe Size:   8
     
Rate your vision: Good
Your normal vision uncorrected is about:   20/
Do you require glasses or contacts?   Yes
Do you have: Nearsightedness    Farsightedness    Astigmatism
     
Rate the condition of your hearing: Excellent
     
Rate the condition of your teeth: Good
Any periodontal or gum disease?   No
Have you had any of the following?   Caps    Inlays    Crowns    Onlays
    Veneers   Dental Implants   Bridges
    Braces    Dentures
     
Do you have any allergies? Yes
If yes, please describe:
Amoxicilian, Penicilian, Ethromycin, Gentimycin, Ibuprofen, Sudafed
(Food, medicine, pollen)
 
Any birth defects? No
If yes, please describe:
(Even if minor or correctable)
 
 
Personal Questions:
Are you currently a smoker? No
If you smoke, how much?   Packs/Day
If you have quit, what was the approximate date?   0000
     
Do you drink alcohol? Yes
If yes, how much?   less than 1 drink /Week
     
Do you or have you used any non-prescription drugs? No
If yes, please describe:
 
Do you or have you used any prescription drugs? No
If yes, please describe:
 
Do you or have you used any illegal drugs? No
If yes, please describe:
 
Have you ever had a drug or alcohol abuse problem? No
If yes, please describe:
 
Are you currently suffering from and/or been    
diagnosed or treated for Anorexia/Bulimia? No
If yes, please describe:
 
Have you ever been under the care of a Psychiatrist? No
If yes, please describe:
 
Have you ever been under the care of a Psychologist/Family Therapist? No
If yes, please describe:
 
Have you ever had any psychiatric hospitalizations? No
If yes, please describe:
 
Have you ever been arrested or convicted of a crime? No
If yes, please describe:
 
Have you ever had surgery of any type?    
(including cosmetic surgery) Yes
If yes, please describe:
2 C-Sections with my children, and a PDA-Paten Ductus Artery Heart Surgery when born. I was born 3 months premature and had to have a PDA performed. Breast Augmentation and Reduction.
 
Have you ever had a blood transfusion? No
If yes, please describe:
 
Have you ever been diagnosed with an STD?
If yes, please describe:
 
Do you have any tattoos? Yes
Approximate date of your last tattoo?   1997
 
 
Fertility Profile:
Age when you first started your menstrual cycle: 14
Are your cycles regular?   Yes
How many days between your monthly cycle?   30
Date of last cycle:   2007
What is the birth control you are currently using?   Abstinence
How many children do you have living with you?   2
What are their ages?   8 and 7
     
How many pregnancies have you had? 2
 
Have you had any trouble becoming pregnant?    
(taking longer than six months) No
If yes, please explain:
 
Have your parents or siblings experienced difficulties    
becoming pregnant? (conceiving) No
If yes, please explain:
 
Was your mother administered diethylstilbestrol (DES) or any    
other prescription drug while she was pregnant with you? No
If yes, please list the known prescriptions and the reason it was prescribed:
 
Have you ever had any of the following?
Endometriosis    Hepatitis    HIV Exposure    Hysterectomy
Infected Tubes or Ovaries   Ovarian Cancer  Ovarian Cysts
Ovarian or Uterine Tumor    Pelvic Inflammatory Disease
Removal of Ovary    Removal of Tubes
If yes to any, please explain:
 
 
Delivery History:
 
Delivery Date Birth Weight Length of Labor Single/Multiple Vaginal/C-Section
1 1998 6 lbs 6 hrs Single C-Section
2 1999 6 lbs 4 hrs Single C-Section
3 0000 lbs hrs
4 0000 lbs hrs
5 0000 lbs hrs
6 0000 lbs hrs
 
Character Profile:
How would you describe your personality?  
I have always been a very outgoing person. I am not shy at all. I like to make people happy if they are down and I enjoy giving. I have a big heart, I am a very caring person always thinking about others before myself. I am very down to earth and humble. I am very mature for my age and having children has made me more mature. I am very driven, goal oriented, and ambitious. I like to be outdoors and go places and see things that I have never seen before. Sometimes I can get a little temper when all of my buttons have been pushed but it takes alot to get me upset. I am generally a happy person and my mom said that I was a happy baby who did not cry much. I am not a jealous person, I do not find the need to be jealous over someone. I am happy for those who have worked hard for what they have.
(Quiet, Energetic, Artistic, Etc.)
 
Describe you special interests, hobbies, talents:
Baking-Especially Desserts, Crafts, Sewing, Crocheting, Dancing, Yoga and Pilates, Shopping, Camping and the outdoors, Amusement Parks-Roller Coasters
 
Do you have any special goals you are working towards?  
Yes, I am currently a full time student looking to graduate in April 2008 with my BS in Accounting. I then wish to Sit for the CPA Exam to be a Certified Public Accountant. Once I pass I will continue my education in pursueing my Master's in Taxation or Audting. My Ultimate goal is to be an Forensic Accountant.
(personal or professional)  
   
Do you participate in any sports or recreational activities? Yes
If yes, please describe:
Softball, Soccer, Walking, Running, Excercising-Yoga and Pilates
 
How do you view other women who have suffered with infertility?  
Its an unfortunate thing to have to go through. I personally have a close friend that has dealt with this issue, and its hard. To be able to have a baby and bring life into this world is a beautiful and joyous experience that all women should be able to get the opportunity to experience.
   
What does being an Ovum Donor mean to you?:
Its very meaningful to me...I am helping out a couple or individual bring new life into this world. I feel that I am able to help someone by donating my eggs so they can too experience the joys of motherhood and know how great it is to bring a child into this world.
 
How do you think your family and close friends will view your decision to become a Donor?  
They are very suportive of me, I have donated before and the experience was AWESOME!
   
 
Educational Profile:
Are you currently a student? Yes
What is your current GPA?   3.2
What is your current Major?   Accounting
     
Highest level of education completed:   Some College
Degree/Diploma/Certification:   AA Degree
     
High School GPA:   3.0
SAT Score:  
ACT Score:  
What are/were your best subjects?   Math and History/Culture
     
Do you or have you ever struggled with any learning disabilities? No
If yes, please explain:
 
What are your ultimate career goals or desires?
I plan to graduate in April 2008 with my BS in Accounting, then site for the California CPA Exam so I can be a Certified Public Accountant, then continue my education towards my Master's in eiether Taxation or Auditing..with my career goal of being an Forensic Accountant.
 
Have you ever taken an I.Q. test? Yes
If yes, test results:   Not Sure
Date of testing:   2006
     
Would you be willing to submit to I.Q. testing if requested by    
the intended/prospective parents? (at their expense) Yes
     
 
Family Education History:
MGM: Maternal Grandmother
MGF: Maternal Grandfather
PGM: Paternal Grandmother
PGF: Paternal Grandfather
 
Attended College Graduated College Special Career Talents/Accomplishments
You Yes No
Almost finished with my Bachelors in Accounting will graduate in April of 08'
Mother Yes No
Only some general education college work complted. Regional Manager for a large Electronics Sales Company.
Father Yes No
Only some general education college work complted. Sr. VP Telemarkerter for large West Coast Insurance Company.
Sibling Yes Yes
CNA, and is currently attending college for her RN.
Sibling
Sibling
Sibling
MGM
MGF
PGM
PGF
 
Genetic Profile:
Were you adopted? No
If yes, do you know your birth parents' genetic background?  
     
Maternal Ethnic Ancestry: Irish/American Indian
Paternal Ethnic Ancestry:   German
(Example: Irish/Italian, please be specific, do not
answer the above White/Caucasian, etc.)
     
Are you of Mediterranean (Greek or Italian) descent? No
If yes, have you ever been tested as a carrier of Thalassemia?  
If yes, results:  
     
Are you of Jewish descent?   No
If yes, have you ever been tested as a carrier of Tay Sachs Disease?   No
If yes, results:  
     
Are you of African descent?   No
If yes, have you ever been tested as a carrier of Sickle Cell Disease?   No
If yes, results:  
     
Please describe any known genetic conditions or birth defects in your family:
 
 
Family History:
 
Mother  
Date of Birth:
11/23/1955
Age at death and cause of death (if applicable):  
Height: 5 Ft   6 In
Weight: 130 Pounds
Race: Caucasian
Eye Color: Brown
Natural Hair Color: Brown
Unique skills or abilities:
 
Father  
Date of Birth:
06/10/1952
Age at death and cause of death (if applicable):  
Height: 6 Ft   3 In
Weight: 170 Pounds
Race: Caucasian
Eye Color: Blue
Natural Hair Color: Brown
Unique skills or abilities:
 
Sibling #1  
Sibling Gender: Female
Date of Birth:
07/17/1977
Age at death and cause of death (if applicable):  
Height: 5 Ft   4 In
Weight: 140 Pounds
Race: Caucasian
Eye Color: Blue
Natural Hair Color: Brown
Unique skills or abilities:
 
Sibling #2  
Sibling Gender:
Date of Birth:
 
Age at death and cause of death (if applicable):  
Height: Ft   In
Weight: Pounds
Race:
Eye Color:
Natural Hair Color:
Unique skills or abilities:
 
Sibling #3  
Sibling Gender:
Date of Birth:
 
Age at death and cause of death (if applicable):  
Height: Ft   In
Weight: Pounds
Race:
Eye Color:
Natural Hair Color:
Unique skills or abilities:
 
Sibling #4  
Sibling Gender:
Date of Birth:
 
Age at death and cause of death (if applicable):  
Height: Ft   In
Weight: Pounds
Race:
Eye Color:
Natural Hair Color:
Unique skills or abilities:
 
Sibling #5  
Sibling Gender:
Date of Birth:
 
Age at death and cause of death (if applicable):  
Height: Ft   In
Weight: Pounds
Race:
Eye Color:
Natural Hair Color:
Unique skills or abilities:
 
If you have more than five siblings, enter the information above for each one here:
 
Family Medical/Genetic History:
 
Disease: You Your Children Your Mother Your Father Siblings Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather None
Acne
Adrenal Dysfunction
Adrenal Disorder
AIDS
Alcoholism
Allergies
Alzheimer's Disease
Anemia
Arthritis
Asthma
Birth Deformities
Blindness/Color Blindness
Blood Disorders
Breast Cancer
Cancer
Indicate Type Below
Cataracts
Cerebral Palsy
Cervix Cancer
Chemical/Radiation Exposure
Chronic Bronchitis
Disease: You Your Children Your Mother Your Father Siblings Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather None
Chronic Muscle Disease
Cleft Lip
Colitis
Colon Cancer
Convulsions
Creutzfeldt-Jacob Disease
Crohn's Disease
Cystic Fibrosis
Deafness (Birth/Childhood)
Deafness (before age 50)
Diabetes
Drug Abuse
Down's Syndrome
Dwarfism
Ear Deformity
Eczema
Epilepsy
Extreme Nervousness
Eye Disease
Gallstones
Disease: You Your Children Your Mother Your Father Siblings Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather None
Goiter
Gout
Glasses/Contact Lenses
Gaucher's Disease
Glaucoma
Hardening of Arteries
Hayfever
Heart Attack
Indicate Age Below
Heart Disease
Heart Murmur
Hemophilia
Hepatitis
High Blood Pressure
Huntington's Disease
Hydrocephalus
Hyperactivity
Hypoglycemia
Hypospadias
Immune Deficiency
Intestinal Cancer
Disease: You Your Children Your Mother Your Father Siblings Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather None
Kidney Problems
Learning Disability
Leukemia
Liver Disease/Cirrhosis
Liver Cancer
Lower Back Disorders
Lung Disease/Emphysema
Lung Cancer
Lupus
Manic Depression
Mental Illness
Mental Retardation
Migraines
Multiple Sclerosis
Muscular Dystrophy
Nervous System Problems
Obesity
Osteoporosis
Ovarian Cancer
Ovarian Cysts
Disease: You Your Children Your Mother Your Father Siblings Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather None
Paralysis
Parkinson's Disease
Pigmentation Disorders
Pneumonia
Prostate Cancer
Psychological Imbalance
Retinal Blastoma
Schizophrenia
Senility (before age 50)
Sickle Cell Anemia
Skin Cancer
Skin Conditions/Disorders
Speech Problems
Spina Bifida
Stroke
Tay Sachs Disease
Thalassemia
Thyroid (High or Low)
Thyroid Cancer
Tuberculosis
Disease: You Your Children Your Mother Your Father Siblings Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather None
Tumors
Ulcerative Colitis
Ulcers
Undescended Testicle
Uterine Cancer
Uterine Fibroid
Wilson's Disease
Other (Describe Below):
 
Please elaborate on above where necessary:
My Maternal Grandmother had Breast Cancer in both Breasts..survived. And then later got Ovarian Cancer which eventually spread to her Lungs and all over her body.
 
 
Photographs:



donor modeling


donor modeling


 
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