Egg Donor Application

Name 姓名 *

First

Last

DOB 生日 (MM/DD/YYYY) *

Age 年齡 *

Height 身高 *

Weight 體重 *

Blood Type 血型 *

Maternal Ethnic Origin 母系家族血統 *

Paternal Ethnic Origin 父系家族血統 *

Marital Status 婚姻狀態 *

Religion 宗教信仰

School attending / Graduated 畢業於哪所學校

Occupation 職業 *

Length of employment 就職時間

Address 地址 *

Home Phone Number 家用電話 *

Cell Phone Number 手機號碼 *

Email 電子郵箱 *

Residency 居留權 *

U.S. citizen 美國公民
Green Card 綠卡
Visa 簽證

If you are not a U.S. citizen, please indicate your citizenship 國籍 *

Health Insurance Carrier 保險公司

Policy Holder 保險方案所有者

Group # 團體號碼

Policy # 保險方案號碼

Name of Emergency Contact 緊急聯絡人姓名 *

Relationship 與您的關係 *

Emergency Contact Number 聯繫人的電話號碼 *

How Did You Hear About Us 如何得知我們 *

Natural Eye Color 眼睛顏色 *

Natural Hair Color 自然髮色 *

Hair Texture 自然髮質 *

Complexion 自然膚色 *

Predominant Hand 習慣用手

Right Handed 右撇子
Left Handed 左撇子
Ambidextrous 左右均可

Years of High School Completed 讀完幾年高中

GPA 平均成績

Years of College Completed 讀完幾年大學

GPA 平均成績

Major 主修 / Minor 副修

Have you ever had/Do you have any learning disabilities 您是否有(過)學習障礙? *

Yes 是
No 否

Have you ever been an egg donor before 您之前有否捐過卵? *

Yes 是
No 否

If yes, how many times 如有，請問共捐過多少次? *

How many eggs were retrieved each time 每次各取得多少個卵子?

Did any of the eggs result in pregnancy 這些卵子有否幫助到受贈者懷孕?

Yes 是
No 否
Don't know 不知道

What is the reason you want to be an egg donor 您考慮捐卵的原因 *

Which of the following describes you 以下選項最能形容您的性格? *

What are your favorite books 最喜歡的書籍? *

What are your favorite colors 最喜歡的顏色? *

What are your favorite foods 最喜歡的食物? *

What kind of sports do you enjoy 喜歡什麼運動? *

What languages do you speak 您會說哪些語言? *

What are your hobbies 您的興趣愛好是什麼? *

Please describe any special talents, skills, or abilities you have 請形容任何你所會的特別才藝和技能. *

How often do you get your period 月經多久一次? *

How many days does your period last 月經持續幾天? *

Do you consider your period regular月經週期是否規律? *

Yes 是
No 否

If no, please describe 如不規律, 請描述.

The flow is 流量

Light 偏少
Moderate 中等
Heavy 偏多

How many times do you change your pads/tampons 每天換幾次衛生棉?

Sexual Orientation 性取向: *

Heterosexual 異性戀
Bisexual 雙性戀
Homosexual 同性戀

Are you currently sexually active 目前有沒有性生活? *

Yes 有
No 沒有
With male 與男性
With female 與女性

Are you currently using birth control 目前在用避孕措施? *

Yes 是
No 否

Method of birth control 避孕方式 *

How long have you been using this birth control 已使用避孕方式多久? Are there any side effects 是否有任何副作用? *

Number of Pregnancy 懷孕過幾次? *

Number of Children 生過幾個孩子? *

# of Vaginal Delivery 幾次自然產? *

# of C-Section 幾次剖腹產? *

Have you ever had a miscarrige 是否有過自然流產? *

Yes 是
No 否

Have you ever had an induced abortion 是否有過墮胎？ *

Yes 是
No 否

Have you ever had a stillbirth 是有否有過死胎? *

Yes 是
No 否

Child #1 孩子 #1

Child #2 孩子 #2

Child #3 孩子 #3

Child #4 孩子 #4

Please list any complications you had for each delivery 請列出生孩子過程所產生的任何併發症.

Please list weeks at birth for each child 請列出每位孩子的孕期.

Please list any health problems for each child 請列出每位孩子的健康問題.

Are you currently under a physician's care for any reason/condition 目前有否因為任何狀況而看醫生? *

Yes 是
No 否

If yes, please explain 如有, 請說明.

The date of your last pap smear 您上次做子宮頸抹驗檢查的日期

Pap Smear Result 子宮頸抹驗檢查結果

Normal 正常
Abnormal 不正常
Don't know 不知道

The date of your last HIV/AIDS screening 您上次做艾滋病病毒檢查的日期

HIV/AIDS Result 愛滋病毒檢查結果

Normal 正常
Abnormal 不正常
Don't know 不知道

Have you ever been diagnosed with any of the Sexually Transmitted Diseases (STD) below 您是否曾經檢查出以下任何傳染疾病? *

Has your partner ever been diagnosed with any of the Sexually Transmitted Diseases (STD) below 您的伴侶是否曾經檢查出以下任何傳染疾病? *

Have you had vaccination for the following 您是否曾接受過以下疫苗? *

If never vaccinated, willing to receive vaccination 如從未接種, 是否願意接受疫苗? *

Yes 是
No 否

Please list all the current medications you are taking (prescription, OTC, herbs) 請列出目前服用的藥物(處方藥, 非處方藥, 中藥) *

Please list all allergies and your reaction to each 請列出所有的過敏原和症狀. *

How is your apetite 您的胃口如何? *

Describe what type of food your regular diet is consisted of 請描述一下您的平時的飲食.

Are you near-sighted 您是否近視? If yes, you wear 如是, 您戴 *

Yes 是
No 否
Contacts 隱形眼鏡
Glasses 眼鏡

What is the condition of you teeth 您的牙齒狀況如何? *

Excellent 非常好
Good 好
Fair 普通
Poor 不好

Do you drink alcohol 您喝酒嗎? *

Yes 有
No 沒有

If yes, how many drinks per week 如有, 每週喝多少?

Do you have history of alcohol abuse 您是否有(過) 酗酒的習慣? *

Yes 有
No 沒有

Do you smoke cigarettes 您吸煙嗎? *

Yes 有
No 沒有

If yes, how many per day 如有, 每週吸多少根?

Do you use/have you ever used illicit drugs 您使用(過)違禁毒品嗎? *

Yes 有
No 沒有

If yes, please explain 如有，請說明

Are you/Have you ever been under the care of a psychiatrist? 目前或過去是否看過精神科? *

Yes 是
No 否

If yes, please explain 如有，請說明

Have you ever been convicted of a crime or felony 是否有犯罪記錄? *

Yes 是
No 否

If yes, please explain 如有，請說明

Do you have any tattoos 有沒有紋身? *

Yes 是
No 否

If yes, please list date and location on body 如有，請列出日期和紋身位置

Do have any piercing 有沒有穿過洞? *

Yes 是
No 否

If yes, please list date and location on body 如有，請列出日期和穿洞位置

Have you had any plastic surgery 是否有做過整形或微整形手術? *

Yes 是
No 否

If yes, please list date and location 如有，請列出日期和整形部位

Do you have recurring/unresolved headaches 是否有復發持續性頭痛/頭暈? *

If yes, how often per week 如有，一周幾次?

Do you now have/Have you ever had any of the following conditions 您現在或過去是否有過以下的情况? (Please check all that apply 請勾選所有符合的項目) *

In the past month, have you had any of the following problems 過去的一個月內您是否有以下的症狀? (Please check all that apply 請勾選所有符合的項目) *

Please list your father/mother's age, height, weight, education, occupation, health and psychiatric. If deceased, please list age and cause. 請列出您父母的年齡, 身高, 體重, 教育程度, 職業, 身心疾病(如有). 如往生, 請寫出過世年齡及原因. *

Please list your paternal grandfather/grandmother's age, height, weight, education, occupation, health and psychiatric. If deceased, please list age and cause. 請列出您祖父及祖母的年齡, 身高, 體重, 教育程度, 職業, 身心疾病(如有). 如往生, 請寫出過世年齡及原因. *

Please list your maternal grandfather/grandmother's age, height, weight, education, occupation, health and psychiatric. If deceased, please list age and cause. 請列出您外祖父及外祖母的年齡, 身高, 體重, 教育程度, 職業, 身心疾病(如有). 如往生, 請寫出過世年齡及原因. *

Please list your sibling's age, height, weight, education, occupation, health and psychiatric. If deceased, please list age and cause. 請列出您兄弟姊妹的年齡, 身高, 體重, 教育程度, 職業, 身心疾病(如有). 如往生, 請寫出過世年齡及原因. *

Have you or your family members ever had difficulty conceiving? 您或您的親屬是否有(過)不易懷孕的困擾? *

Yes 有
No 沒有

If yes, please explain in details 如有, 請說明

Please list any extended family members' physical and psychiatric problems (past and present) 請列出任何其他親戚現在及過往的身體及心理健康問題 *

Egg donors are required to have Infectious Disease Screening Tests at the expense of the Intended Parents 捐卵者需要接受傳染病檢查，費用將由受贈者支付。 *

Understood 了解

Egg donors must abstain from sexual activity or stimulation while undergoing the egg donation cycle unless they have had a Tubal Ligation or their partner has had a vasectomy 除非已經結紮，捐卵者在捐卵過程期間必須停止所有性生活或引起性欲的活動。 *

Understood 了解

Egg donors are required to attend approximately 8 to 10 appointments throughout the donation cycle. 捐卵過程期間，捐卵者必須要參與8到10次的門診。 *

Understood 了解

Egg donors are required to take self-administered injections for approximately 3-4 weeks. 有三到四周的時間，捐卵者必須自行注射所需藥物。 *

Understood 了解

Egg donors are required to undergo a procedure under sedation to retrieve the eggs from their ovaries. 捐卵者在取卵時必需經過麻醉及手術。 *

Understood 了解

Egg donors are required to have reliable transportation for appointments. 捐卵者必需要有可靠的交通運輸工具。 *

Understood 了解

Egg donors are required to have a driver on the day of the egg retrieval. 捐卵者在取卵當天必需由他人接送。 *

Understood 了解

No legal fees, psychological testing fees, medical testing fees or medical procedure fees will be charged to the applicant. 捐卵者無需擔負律師、心理評估、醫療檢查之費用，但是其它支出(包括交通費、保姆費等)必須由捐卵者自行負責。 *

Understood 了解

I consent to being notified of any medical information discovered about me during the egg donation process. 我同意被告知在捐卵過程中所發現的關於我的健康信息。 *

Understood 了解

I AUTHORIZE THE RELEASE OF ANY NON-FICTIONAL INFORMATION AND PHOTOGRAPHIC MATERIAL ENCLOSED IN THIS APPLICATION. 我允許除姓名及隱私以外的資料和照片被使用。 *

Understood 了解

Electronic Signature 電子簽名 *

Please enter your first and last name in this field. 請輸入您的名字.