Yumurta Donör No 153

q

Egg Donor Registration Form

Personal Information

Code

EVGENIA TAVALIUK

Date of Birth

01/06/1998

Age

20

Nationality

GEORGIA

Place of Birth

MOLDOVA

Blood group

O

Rhesus Factor

Rh(+)

Marital status :

☑married ☐ single ☐divorced ☐engaged ☐ in partnership

Do you have child/children?

Yes No

If yes, how many?

Info about child/children

Gender : 4-3

Age:

Employment

Housewife

Employed ☐place of employment Shop assistant

Do you smoke?

Yes No

Do you consume alcohol?

Yes No

Do you take any illegal drugs?

Yes No

Physical Characteristics

Height (cm) 155

cm

Weight (kg)

Kg

Weight (kg) 50

Skin Color

Fair

Medium

Dark

Eye Color

Black

Brown

Blue

Green

Other

Natural Hair Color

Black

Brown

Blond

Red

Education (Check all that apply)

School +

College

University Major :

Other

Occupation

Skills/hobby

Are you involved in any sport activity? Which one?

No

What do you like to do at your free time?

☒reading☑Listening to Music ☒ Walking ☐Painting ☐Singing ☐Knitting

☐Other

Do you have allergies?

Yes No

If yeas, please explain

Do you wear eye-glasses?

Yes No

Are you left -handed?

Yes No

Family History

Do you have twins in family or among relatives?

☐ Yes Who has?

☐No

Age

Eye Color

Hair Color

Hair Type

Height

Blood Group and Rhesus

Nationality

Mother

52

green

black

straight

157

Father

55

green

black

straight

169

Brother 1

2

3

3

Sister 1

2

3

4

Occupation of Mother

Housewife

Occupation of Father

Shop assistant

Donation History

How many donations have you had?

None One Two Other

When did you donate?

Date: Resulted in Pregnancy : Yes No

Date :

Resulted in Pregnancy : Yes No

At which clinic did you donate?

Have you carried out genetic test/tests? Yes No

Do you have the following disease:

AIDS(HIV)

Yes

No

Herpes

Yes

No

Gonorrhea

Yes

No

Chlamydia

Yes

No

Genital Warts

Yes

No

Syphilis

Yes

No

Hepatitis

Yes

No

Tuberculosis

Yes

No

Allergies to medication

Yes

No

Previous surgery

Yes

No

Medical Problem

You

Your Family

Comment ( if yes, please explain)

Diabetes

Yes

No

Yes

No

Heart Disease

Yes

No

Yes

No

Asthma

Yes

No

Yes

No

Genetic Disease

Yes

No

Yes

No

Mental Disease

Yes

No

Yes

No

Age when you had your first period

13

What is your menstrual bleeding like ?

Regular Non-regular

How long does your menstrual bleeding usually lasts?

4

Have you had abortion?

Yes No

If yes, how many times

Have you had a miscarriage?

Yes No

If yes, how many times



Are you willing to donate abroad?

Yes

Are you willing to donate to couple regardless of their nationality/citizenship?

Yes

Is there any current lawsuit against you ?

No