Egg donor interview

Munasolulahjoittajan lomake EN

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Personal Data

Last name

First names

Personal identity code

Age

Street address

Post code

City/municipality

Email address

Phone number

Skype address

Physical characteristics and ethnicity

Ethnic group: Finnish/something else, please specify

Height

Weight

Skin colour: white/black/something else, please specify?

Hair colour: blond/light brown/dark brown/black/red

Eye colour: blue/grey/brown/green

About being a donor

Why do you want to donate eggs?

Have you donated eggs before?

Menstrual cycle

Age at the first menstrual period?

Duration of menstrual cycle (days)? Is your cycle regular?

Genital organs

Have you ever had any genital diseases: inflammation/endometriosis/genital cancer/other, please specify.

Contraception

Which method of contraception do you use: no contraception/condom/contraceptive pill, for how many years/coil, for how many years/male sterilisation, year/female sterilisation, year/other, please specify.

Pregnancy history

Childbirths, years

Have you been previously treated for infertility? Where and what kinds of treatments?

State of health

Do you have any chronic diseases? (e.g. diabetes, gastric ulcer, arterial hypertension, gastrointestinal disorders, recurrent respiratory tract infections or some other chronic disease)

Have you had any operations?

Do you have any allergies?

Have you or your partner been abroad during the last 6 months? If yes, where?

Medication

Do you take medications regularly? If yes, please specify.

Stimulants

Smoking: no / yes (number of cigarettes per day)

Units of alcohol (per week, month)1 unit = 12 cl of medium alcohol content wine, 33 cl of cider/beer, 4 cl of spirits

Do you take or have you ever taken or tried drugs? If yes, what and when:

Illnesses and diseases in your immediate family

Do you or anyone in your family have any hereditary diseases or deformities? If yes, who and what kind?

Do you or your close relatives (your own parents, siblings or your own children) have mental health problems (e.g. bipolar disorder or schizophrenia) OR attention deficit disorder (such as ADHD or other attention deficit disorder)? If so, what?

Have you or anyone in your family undergone a chromosome analysis or a test for a hereditary disease? If yes, which test or analysis and what was the result?

Does anyone in your family have any of the following diseases and if yes, who:

	mother	father	sister	brother	own child	grandparent
arterial hypertension
diseases of the respiratory system
diabetes
rheumatic or connective tissue diseases
kidney diseases
epilepsy
multiple sclerosis
other neurological diseases

Somewhere else:

Other factors that may influence donation of eggs, and possible wishes or comments:

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