Egg Donor Application 個人資訊 姓名（名字、中間名、姓）： 出生日期 Age 地址 街道地址 街道地址（第二行） 城市 州 郵遞區號 聯絡資訊 電子郵件 電話 其他人 高度 重量 Eye Color Hair Color Ethnic origin Ethnic of mother Ethnic of father Highest Level of education and Major Blood Type Current living country What is your current occupation? Do you wear or have you worn eyeglasses? Have you worn braces? Where did you grow up? Marital Status Describe your personalities Why do you want to become a donor? Being a donor is a big responsibility. It requires going to several doctor's appointments, taking injections and hav-ing minor out-patient surgery. Do you feel prepared to commit to this process? 是的 不 Are you open to being matched with all types of families regardless of sexual preference, marital status, ethnicity or sex of the egg recipient? 是的 不 If they request it, are you willing to meet your intended parents? 是的 不 Are you open to meeting the child in the future if that is requested? 是的 不 Are you open to exchanging future contact information with your intended Parents(s)? 是的 不 Do you have any siblings? If so, tell us about each of them: 是的 不 Do you have any children? If so, tell us about each of them: 是的 不 Medical Information Any past or current medical problems (including surgeries, accidents, birth defects, depression, etc.)? If yes, please list: 是的 不 Do you have any known genetic disorders? If yes, please list: 是的 不 Have you ever been pregnant? If yes, how many times and what was the outcome? 是的 不 Have you ever been a donor before? If yes, did a pregnancy occur? 是的 不 Are you currently taking any medication (for physical or mental health)? If yes, what medications are you on and why? 是的 不 Are you taking any recreational drugs? If yes, what are you taking? 是的 不 How often do you exercise? Family Member Information Father Age 高度 職業 Motherr Age 高度 職業 Paternal grandfather Age 高度 職業 Maternal grandfather Age 高度 職業 Maternal grandmother Age 高度 職業 Sibling #1 Age 高度 職業 Sibling #2 Age 高度 職業 Sibling #3 Age 高度 職業 If you have more than 3 siblings, please give their age, height and occupation below. Family Member Information - disorders Family Member Father Mother Paternal Grandfather Paternal Grandmother Maternal Grandfather Maternal Grandmother Sibling #1 Sibling #2 Sibling #3 Age Mental Retardation 癌症 Intellectual Disability Autism Spectrum Disorder Congenital Physical Malformation Cystic Fibrosis Lupus Hypertension (High Blood Pressure) Memory Loss / Dementia 憂鬱症 Kidney Disease Bipolar Disorder Cardiomyopathy Allergies / Hay Fever ADHD (ADD/ADHD) 貧血 Birth Defects Blindness History of Blood Transfusion Canavan Disease Additional information Family Member Father Mother Paternal Grandfather Paternal Grandmother Maternal Grandfather Maternal Grandmother Sibling #1 Sibling #2 Sibling #3 Age Mental Retardation 癌症 Intellectual Disability Autism Spectrum Disorder Congenital Physical Malformation Cystic Fibrosis Lupus Hypertension (High Blood Pressure) Memory Loss / Dementia 憂鬱症 Kidney Disease Bipolar Disorder Cardiomyopathy Allergies / Hay Fever ADHD (ADD/ADHD) 貧血 Birth Defects Blindness History of Blood Transfusion Canavan Disease Additional information Family Member Father Mother Paternal Grandfather Paternal Grandmother Maternal Grandfather Maternal Grandmother Sibling #1 Sibling #2 Sibling #3 Age Mental Retardation 癌症 Intellectual Disability Autism Spectrum Disorder Congenital Physical Malformation Cystic Fibrosis Lupus Hypertension (High Blood Pressure) Memory Loss / Dementia 憂鬱症 Kidney Disease Bipolar Disorder Cardiomyopathy Allergies / Hay Fever ADHD (ADD/ADHD) 貧血 Birth Defects Blindness History of Blood Transfusion Canavan Disease Additional information If you have more than 3 familiy members with medical disorders, please specify with details below. 你能發送幾張你的照片給我們嗎？ 我在此宣誓或聲明，上述及前述的陳述，依據我所知、所信，均屬真實無誤。. 簽署日期 寄送
