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Egg donor interview

Ovumia Fertinova Tampere:


The form is sent securely using a safe connection.

Personal Data

Last name (required)

First names (required)

Personal identity code (required)

Age

Street address

Post code

City/municipality

Telephone number

E-mail

Occupation

Account number for travel allowance

Are you in a permanent relationship?

Relationship since year (marriage, cohabitation)

 

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

Where did you learn about egg donation? Please list all the places where you have heard or read about it.

Why do you want to donate eggs?

Does your partner know about your decision to become a donor?

Does your partner accept you being a donor?

Have you donated eggs before?

 

Menstrual cycle

Age at which you had your first period

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

Duration of menstrual flow

Flow quantity: average/heavy/light

Do you have period cramps? If yes, please specify any medication you take for it?

The dates of the first days of your period over the last six months

 

Genital organs

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

When did you last have a gynaecological smear test, i.e. a Pap smear?

Have you ever had: chlamydia/gonorrhoea/condyloma/other sexually transmitted disease, please specify which and when.

 

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

Miscarriages, years

Ectopic pregnancies, years

Abortions, years

Have any of your pregnancies begun through fertility treatments?

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 ever had a malignant tumour? If yes, what treatment(s) were you given: operation/radiotherapy/cytotoxins

Have you had any operations?

Do you have any allergies?

Have you previously (before this donation) had any of the following medical examinations: HIV/Hepatitis B/Hepatitis C? When was the examination performed (date) and what was the result?

Have you received any blood products during the last 12 months?

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.

Have you ever been given hormone therapy?

 

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?

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: arterial hypertension, diseases of the respiratory system, diabetes, allergy, rheumatic or connective tissue diseases, kidney diseases, epilepsy/multiple sclerosis/other neurological diseases, haemorrhagic disease (e.g. haemophilia, porphyria), muscular dystrophy, cancer, mental disorders (e.g. schizophrenia, bipolar disorder), skin diseases, bone diseases, visual impairment, hearing defects, children born small or stillborn, other?


 

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


 

Ovumia Fertinova Helsinki:


The form is sent securely using a safe connection.

Personal Data

Last name (required)

First names (required)

Personal identity code (required)

Age

Street address

Post code

City/municipality

Telephone number

E-mail

Occupation

Account number for travel allowance

Are you in a permanent relationship?

Relationship since year (marriage, cohabitation)

 

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

Where did you learn about egg donation? Please list all the places where you have heard or read about it.

Why do you want to donate eggs?

Does your partner know about your decision to become a donor?

Does your partner accept you being a donor?

Have you donated eggs before?

 

Menstrual cycle

Age at which you had your first period

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

Duration of menstrual flow

Flow quantity: average/heavy/light

Do you have period cramps? If yes, please specify any medication you take for it?

The dates of the first days of your period over the last six months

 

Genital organs

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

When did you last have a gynaecological smear test, i.e. a Pap smear?

Have you ever had: chlamydia/gonorrhoea/condyloma/other sexually transmitted disease, please specify which and when.

 

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

Miscarriages, years

Ectopic pregnancies, years

Abortions, years

Have any of your pregnancies begun through fertility treatments?

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 ever had a malignant tumour? If yes, what treatment(s) were you given: operation/radiotherapy/cytotoxins

Have you had any operations?

Do you have any allergies?

Have you previously (before this donation) had any of the following medical examinations: HIV/Hepatitis B/Hepatitis C? When was the examination performed (date) and what was the result?

Have you received any blood products during the last 12 months?

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.

Have you ever been given hormone therapy?

 

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?

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: arterial hypertension, diseases of the respiratory system, diabetes, allergy, rheumatic or connective tissue diseases, kidney diseases, epilepsy/multiple sclerosis/other neurological diseases, haemorrhagic disease (e.g. haemophilia, porphyria), muscular dystrophy, cancer, mental disorders (e.g. schizophrenia, bipolar disorder), skin diseases, bone diseases, visual impairment, hearing defects, children born small or stillborn, other?


 

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


 

Ovumia Fertinova Jyväskylä:


The form is sent securely using a safe connection.

Personal Data

Last name (required)

First names (required)

Personal identity code (required)

Age

Street address

Post code

City/municipality

Telephone number

E-mail

Occupation

Account number for travel allowance

Are you in a permanent relationship?

Relationship since year (marriage, cohabitation)

 

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

Where did you learn about egg donation? Please list all the places where you have heard or read about it.

Why do you want to donate eggs?

Does your partner know about your decision to become a donor?

Does your partner accept you being a donor?

Have you donated eggs before?

 

Menstrual cycle

Age at which you had your first period

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

Duration of menstrual flow

Flow quantity: average/heavy/light

Do you have period cramps? If yes, please specify any medication you take for it?

The dates of the first days of your period over the last six months

 

Genital organs

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

When did you last have a gynaecological smear test, i.e. a Pap smear?

Have you ever had: chlamydia/gonorrhoea/condyloma/other sexually transmitted disease, please specify which and when.

 

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

Miscarriages, years

Ectopic pregnancies, years

Abortions, years

Have any of your pregnancies begun through fertility treatments?

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 ever had a malignant tumour? If yes, what treatment(s) were you given: operation/radiotherapy/cytotoxins

Have you had any operations?

Do you have any allergies?

Have you previously (before this donation) had any of the following medical examinations: HIV/Hepatitis B/Hepatitis C? When was the examination performed (date) and what was the result?

Have you received any blood products during the last 12 months?

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.

Have you ever been given hormone therapy?

 

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?

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: arterial hypertension, diseases of the respiratory system, diabetes, allergy, rheumatic or connective tissue diseases, kidney diseases, epilepsy/multiple sclerosis/other neurological diseases, haemorrhagic disease (e.g. haemophilia, porphyria), muscular dystrophy, cancer, mental disorders (e.g. schizophrenia, bipolar disorder), skin diseases, bone diseases, visual impairment, hearing defects, children born small or stillborn, other?


 

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