Yumurta Donör No 154/LENA

donoregg154b

Egg Donor Registration Form

Personal Information

Code

ANI KIRVALIDZE

Date of Birth

05/10/1992

Age

Nationality

GEORGIA

Place of Birth

TBILISI

Blood group

AB

Rhesus Factor

Rh(+)

Marital status :

☐married ☐ single divorced ☐engaged ☐ in partnership

Do you have child/children?

Yes No

If yes, how many? 1

Info about child/children

Gender : GIRL

Age: 3

Employment

Housewife

Employed ☐place of employment MAKE UP

Do you smoke?

Yes No

Do you consume alcohol?

Yes SOMETIME

Do you take any illegal drugs?

Yes No

Physical Characteristics

Height (cm) 165

cm

Weight (kg)

Kg

Weight (kg) 57

Skin Color

Fair

Medium

Dark

Eye Color

Black

Brown

Blue

Green-BAL

Other

Natural Hair Color

Black

Brown

Blond-KUMRAL

Red

Education (Check all that apply)

School

College

University Major : TECHNICAL UNIVERSITY

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? GRAND MOTHER

☐No

Age

Eye Color

Hair Color

Hair Type

Height

Blood Group and Rhesus

Nationality

Mother

45

BLUE

BROWN

Father

45

BAL

BROWN

Brother 1

2

3

APSENT

Sister 1

2

3

Occupation of Mother

NURSE

Occupation of Father

DEAD

Donation History

How many donations have you had?

None One Two Other

When did you donate?

Date: 2017 Resulted in Pregnancy : Yes No

Date : 2018 MARCH

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?

3

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