This questionnaire is confidential. It is used only by EDCD to help us better understand your preferences and help you select your perfect donor. To help with a physical match, please send a photograph of yourself. Once we receive your completed questionnaire, you will be sent egg donor profiles at no charge, which correspond to your preferences indicated. If you desire additional profiles, simply call EDCD to request them or E-Mail us at: info@eggdonorcenter.com

Please complete this questionnaire at your leisure and mail it back to EDCD at:

EDCD
1720 Avenue K
Plano, Texas 75074

If you are unable to print out this questionnaire, call us at (214) 503-6553 and we will send you one immediately.

This procedure must be done within the United States. Are you willing and able to travel to the United States? __________ yes ________no
If yes, please proceed to the remaining questions.
If not, unfortunately we regret to inform you that we cannot help you at this time.
Good luck in your endeavor.
* RED STAR DENOTES REQUIRED FIELDS
 *Male Partner's Last Name________________________________________  
 *Male Partner's First Name________________________________________  MP-MI____
 *Female Partner's Last Name______________________________________  
 *Female Partner's First Name______________________________________  FP-MI_____

 *Street Address________________________________________________________________

 *City__________________________  *State_____  *Zip Code_________________________


 Country__________________________________________

 *Home Telephone__________________________  *Home E-mail_____________________________
 *Cell Phone_______________________________  
 Home Fax Number__________________________ Business or 2nd E-mail______________________
 Male Partner-Work Phone____________________  *Female Partner-Wk. Phone__________________

 *Date of Birth Female_______________________  *Date of Birth Male__________________________
 *Age Female_____________________________  *Age Male_____________________________

 Is it permissible to call either partner at work? --YES [ ] ---NO [ ]

 *Doctor's First Name___________________ Last Name ___________________________

*Who referred you to us? ________________________________________________________________________

 *Will you be using:  *Donor sperm [ ], Husband sperm [ ], Domestic Partner sperm [ ]
 *Will you be using:  *Surrogate (Gestational Carrier) [ ], Carrying the child myself [ ]

 

Please take a moment and answer the following as honestly and completely as possible.

1. Please describe your fertility problem._______________________________________________

______________________________________________________________________________

______________________________________________________________________________

2. *Who is to be our "contact" person throughout the cycle? ______________________________________

* Please fill out the required fields, if not applicable, put N/A.


3. Based on the criteria below, describe YOUR perfect donor.

A. PHYSICAL CHARACTERISTICS:

 Yes! I Like  It Doesn't Matter No, I Don't Want
Looks Like Female Recipient ____________ ________________ _______________
Looks Like Male Recipient ____________ ________________ _______________

Natural Hair Color  Yes! I Like  It Doesn't Matter No, I Don't Want
Blonde ____________ ________________ _______________
Brown ____________ ________________ _______________
Brunette ____________ ________________ _______________
Red ____________ ________________ _______________

Hair Texture  Yes! I Like  It Doesn't Matter No, I Don't Want
Straight ____________ ________________ _______________
Wavy ____________ ________________ _______________
Curly ____________ ________________ _______________
Thick ____________ ________________ _______________

Complexion  Yes! I Like  It Doesn't Matter No, I Don't Want
Fair ____________ ________________ _______________
Medium ____________ ________________ _______________
Dark/olive ____________ ________________ _______________
Yellow ____________ ________________ _______________
Black ____________  ________________  _______________ 


Eye Color  Yes! I Like  It Doesn't Matter No, I Don't Want
 Blue ____________ ________________ _______________
 Green ____________ ________________ _______________
 Hazel ____________ ________________ _______________
 Brown ____________ ________________ _______________

Height Range  Yes! I Like  It Doesn't Matter No, I Don't Want
up to 5'2" ____________ ________________ _______________
5'3" to 5'5" ____________ ________________ _______________
5'6' & up ____________ ________________ _______________

Weight Range  Yes! I Like  It Doesn't Matter No, I Don't Want
Up to 110 lbs. ____________ ________________ _______________
111-130 lbs. ____________ ________________ _______________
131 & up ____________ ________________ _______________

Race  Yes! I Like  It Doesn't Matter No, I Don't Want
Caucasian ____________ ________________ _______________
Native American ____________ ________________ _______________
Hispanic ____________ ________________ _______________
African American ____________ ________________ _______________
Asian ____________ ________________ _______________
Other ____________ ________________ _______________



B. MEDICAL HISTORY:

Blood Type  Yes! I Like  It Doesn't Matter No, I Don't Want
O ____________ ________________ _______________
A ____________ ________________ _______________
B ____________ ________________ _______________
AB ____________ ________________ _______________
Rh+ ____________ ________________ _______________
Rh- ____________ ________________ _______________

Proven Fertility of Donor  Yes! I Like  It Doesn't Matter No, I Don't Want
Successful previous donation ____________ ________________ _______________
Has her biological children ____________ ________________ _______________
C. INTELLIGENCE:

Educational Background  Yes! I Like  It Doesn't Matter No, I Don't Want
High school grad ____________ ________________ _______________
Some college ____________ ________________ _______________
College grad ____________ ________________ _______________
Post grad degree ____________ ________________ _______________

Minimal acceptable GPA  Yes! I Like  It Doesn't Matter No, I Don't Want
up to 2.5 ____________ ________________ _______________
2.6-3.0 ____________ ________________ _______________
3.1-3.6 ____________ ________________ _______________
> 3.7 ____________ ________________ _______________


Minimal acceptable SAT score  Yes! I Like  It Doesn't Matter No, I Don't Want
Up to 900 ____________ ________________ _______________
901-1000 ____________ ________________ _______________
1001-1100 ____________ ________________ _______________
> 1100 ____________ ________________ _______________


Minimal acceptable ACT score  Yes! I Like  It Doesn't Matter No, I Don't Want
up to 19 ____________ ________________ _______________
20-22 ____________ ________________ _______________
23-25 ____________ ________________ _______________
> 25 ____________ ________________ _______________

 

D. OTHER:

Religion of Birth  Yes! I Like  It Doesn't Matter No, I Don't Want
Protestant ____________ ________________ _______________
Catholic ____________ ________________ _______________
Jewish ____________ ________________ _______________
Islamic ____________ ________________ _______________
Other ____________ ________________ _______________

Marital Status  Yes! I Like  It Doesn't Matter No, I Don't Want
Single ____________ ________________ _______________
Married ____________ ________________ _______________
Divorced ____________ ________________ _______________
Living Together ____________ ________________ _______________

Speed of Availability  Yes! I Like  It Doesn't Matter No, I Don't Want
available now ____________ ________________ _______________
can wait ____________ ________________ _______________

 

4. Please rate the following characteristics of an ovum donor, in the order of their importance to you. Use a scale of 1-9 with the number 1 being the most important and the number 9 being the least important.
This question may seem similar to question #4, but it is different. If you have two or more "No, I Don't Want" DONOR CRITERIA above, we must know the ORDER of their importance to you.

 Characteristic  Female Partner  Male Partner
Physical Characteristics (hair color, Eye color, etc.) __________________ __________________
Blood Type __________________ __________________
Medical History __________________ __________________
Proven Fertility __________________ __________________
Inteligence/Education Backround __________________ __________________
Religion of Birth __________________ __________________
Marital Status __________________ __________________
Speed of Availability __________________ __________________
Other Concerns __________________ __________________

 

5. Please state in your own words, the 3 most important factors to you in the order of their importance (ie. speed of availability, cost, donor characteristics).

   FEMALE PARTNER    MALE PARTNER
A. _____________________________ A. ____________________________
B.  _____________________________ B. ____________________________
C. _____________________________ C. ____________________________

6. Please state in your own words, the 3 most important services we can provide for you, as an agency.

   FEMALE PARTNER    MALE PARTNER
A. _____________________________ A. ____________________________
B.  _____________________________ B. ____________________________
C. _____________________________ C. ____________________________


7. When do you anticipate undergoing a cycle of treatment?__________________________

Do you have any particular preferred month?_____________________________________


8. Please describe YOURSELF in the following spaces.

 Description

Female Partner

Male Partner
Hair Color ________________________  _________________________
Hair Texture (straight/curly/wavy) ________________________ _________________________
Complexion ________________________ _________________________
Eye Color ________________________ _________________________
Height ________________________ _________________________
Weight ________________________ _________________________
Age ________________________ _________________________
Blood Type ________________________ _________________________
National Ancestry/Race ________________________ _________________________
Religion ________________________ _________________________
Occupation ________________________ _________________________
Number of Years Married ________________________ _________________________
Education: High School Graduate? ________________________ _________________________
2. College Graduate? ________________________ _________________________
3. Degrees earned and dates

________________________

________________________

_________________________

_________________________
Personal History:
Have either of you:
1. Had psychotherapy?		 ________________________ _________________________
2.Filed for divorce,
dissolution, legal
separation or annulment
of this marriage?		 ________________________ _________________________
3. Recently attended marriage counseling? ________________________ _________________________

Thank you for taking the time to fill this out and help us help you. EDCD will utilize this information to provide you with donors as close to your specifications as possible. This confidential information is used only by EDCD.