Donor Interest Form

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First Name
Name*
First Last
Email*
Phone*
Address*
City State / Province / Region
Height (ft)*
Height (in)*
Weight*
Birthdate*
Ethnicity*
Please explain why you would like to be a donor*
Please upload a photo of yourself
Max. file size: 520 MB.
Have you donated previously?*
How many times have you donated?*
CCI Donor #
Please describe your previous donor experience
Relationship Status*
How did you hear about us?*
How did you hear about us (other)?*

Date of Marriage*
MM slash DD slash YYYY
Is this your first marriage?*
Partner's Profession*
Is your partner supportive of you being a donor?*

Hair Color*
Eye Color*
Race*
Body Frame*
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Ethnic Origin
Blood Type*
Complexion*
Are you a twin?*

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Freckles*
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Moles*
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Dimples*
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Mouth*
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Lips*
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Nose Size*
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Nose Width*
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Nose Length*
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Nose Bridge*
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Other Distinguishing Features
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Eyes Set*
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Eyes Size*
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Eyebrows Arc*
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Eyebrow Thickness*
Hair color at birth*
Hair Texture*
Hair Fulness*

Vision*
Vision Correction*
Is your hearing normal?*
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Are you able to sense palatability of food?*
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Are you able to sense cold, hot, smooth or rough objects?*
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Are you able to sense odors?*

Number of children*
Number of siblings*
Please describe yourself*
How would friends and family describe you?*

How would you describe yourself as a child?*
What is your happiest childhood memory?*
How is/was your relationship with your parents as a youth?*
What is your saddest childhood memory?*
How important was religion in your home growing up?*
What was your favorite game to play as a youth?*

What goals do you have in life?*
Have you achieved any of them?*
Favorite color*
What is your favorite book?*
Favorite sport*
Favorite style of music*
Favorite movie*
Do you like pets? Which one(s)?*
Favorite food*
How do you like spending your free time?*
Fun fact(s) about yourself*
What does a perfect day look like to you?*
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What is the condition of your teeth?*
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Chest Size (inches)*
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Neck Size (inches)*
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Waist size (inches)*
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Shoe Size*

Highest level of education completed*
How were your grades overall?*
What subjects did you excel at in high school?*
High school GPA*
ACT Score*
SAT Score*
Do you plan to go to college?*
What was your college major?*
Which extracurricular activities did you participate in?*
What was your post-graduate major?*
What languages do you speak?*
What academic/professional memberships did/do you have?*
What was your favorite school year and why?*
What are your career goals?*

Mother's Birthdate*
Mother's Height*
Mother's Ethnicity*
Mother's Weight*
Mother's Eye Color*
Mother's Natural Hair Color*
Mother's Highest level of education completed*
Mother's Current or Last Occupation*
Father's Birthdate*
Father's Ethnicity*
Father's Height*
Father's Weight*
Father's Eye Color*
Father's Natural Hair Color*
Father's Highest level of education completed*
Father's Current or Last Occupation*

Sibling 1 Relationship*
Sibling 1 Birthdate*
Sibling 1 Ethnicity*
Sibling 1 Height*
Sibling 1 Weight*
Sibling 1 Eye Color*
Sibling 1 Natural Hair Color*
Sibling 1 Highest level of education completed*
Sibling 1 Current or Last Occupation*
Sibling 2 Relationship*
Sibling 2 Birthdate*
Sibling 2 Ethnicity*
Sibling 2 Height*
Sibling 2 Weight*
Sibling 2 Eye Color*
Sibling 2 Natural Hair Color*
Sibling 2 Highest level of education completed*
Sibling 2 Current or Last Occupation*
Sibling 3 Relationship*
Sibling 3 Birthdate*
Sibling 3 Ethnicity*
Sibling 3 Height*
Sibling 3 Weight*
Sibling 3 Eye Color*
Sibling 3 Natural Hair Color*
Sibling 3 Highest level of education completed*
Sibling 3 Current or Last Occupation*
Sibling 4 Relationship*
Sibling 4 Birthdate*
Sibling 4 Ethnicity*
Sibling 4 Height*
Sibling 4 Weight*
Sibling 4 Eye Color*
Sibling 4 Natural Hair Color*
Sibling 4 Highest level of education completed*
Sibling 4 Current or Last Occupation*
Sibling 5 Relationship*
Sibling 5 Birthdate*
Sibling 5 Ethnicity*
Sibling 5 Height*
Sibling 5 Weight*
Sibling 5 Eye Color*
Sibling 5 Natural Hair Color*
Sibling 5 Highest level of education completed*
Sibling 5 Current or Last Occupation*

Do you have any dietary restrictions?*
Predominant Hand*
Are you taking any prescription medications?*
Please list the medications you're taking and for what purpose*
Have you taken any prescription medications in the past?*
Please list any medications you have taken in the past 5 years and purpose that are not already listed.*
Some centers require their donors to stop taking some of their medications during the donation cycle. Are you willing and able to discontinue the use of your current prescriptions for the entire donation cycle if instructed by a fertility medical professional?*
Do you smoke cigarettes?*
Have you used nicotine or smoked cigarettes at any time in your life?*
Please explain your past nicotine use (including how many packs per day, for how long, and when you quit)*
Have you ever had a blood transfusion?*
Please explain your blood transfusion(s) (including dates)*
Was the blood transfusion performed outside the United States?*
Please explain your international blood transfusion (including dates)*
Have you ever had any major x-ray or radiation exposure?*
Please explain your radiation exposure (including dates)*
Have you ever had any chemical exposure?*
Please explain your chemical exposure (including dates)*
Do you or your partner have plans to travel outside the United States within the next 6 months?*
Where and when will you travel?*
Have you ever been given anesthesia?*
In what year and for what purpose were you given anesthesia?*
Have you ever received alcohol or substance abuse treatment?*
Please explain your alcohol or substance abuse treatment (including dates)*
Has any member of your immediate family ever received alcohol or substance abuse treatment?*
Please explain your family member's alcohol or substance abuse treatment (including dates)*
Do you have any allergies (including drugs and environmental)?*
Please list your allergies*
Do you drink alcohol?*
Have you ever had any problems with having your blood drawn?*
Please describe any problems you've had with getting your blood drawn*

When was your last Pap Smear?*
MM slash DD slash YYYY
Have you had an abdominal pap smear?*
Please explain your abdominal pap smear*
How old were you when you had your first period?*
On average, how long does your period last?*
Do you have a regular monthly period?*
Please describe your period frequency*
What is your current method of birth control?*
On average, how many days are between the first day of your last period and the first day of your next period?*
Please enter a number from 10 to 90.
Have you ever taken birth control pills?*
Which birth control pills have you taken?*
Do you have adverse side effects from birth control pills?*
Please describe your adverse side effects from birth control pills*
Do you have irregular periods when NOT on birth control?*
Please describe your irregular periods when not on birth control*
Any sexually transmitted diseases? You OR your partner*
Please explain you or your partner's STDs*
Have you or your partner been recently diagnosed with an STD or experienced any symptoms in the last 12 months (with the exception of HPV)?*
Please describe you or your partner's recent STD history*
Have you ever had an abnormal reproductive tract?*
Please explain your abnormal reproductive tract*
Have you ever had one functioning ovary?*
Please explain your one functioning ovary*
Have you ever had ovarian cysts?*
Please explain your ovarian cysts*
Have you ever been diagnosed with PCOS?*
Please explain your PCOS*
Tubal Infection?*
Explain your tubal infection*
Endometriosis?*
Please explain your endometriosis*
Uterine Fibroids?*
Please explain your uterine fibroids*
Unsuccessful attempts to conceive a child?*
What was the diagnosis of the unsuccessful attempts?*
Hysterectomy?*
Have you ever been diagnosed infertile?*
Please explain your infertility diagnosis*
Have you ever had sexual intercourse?*
How many sexual partners have you had in the last 6 months?*
Are you comfortable with vaginal exams and ultrasounds as part of this process?*
Are you (and your partner) comfortable with NOT having sexual intercourse for approximately 4-6 week?*
Have you done any prior donations?*
Have you ever been pregnant?*
How many pregnancies have you carried through delivery?*
Are you currently breastfeeding?*
How many miscarriages have you experienced?*
What were the dates (month/year) of your miscarriages and how many weeks pregnant were you for each?*
How many abortions have you had?*
What were the dates (month/year) of your abortions and how many weeks pregnant were you for each?*
Have any of your children died as infants?*
Please explain (including dates) the death(s) of your infant(s)*

Are you adopted?*
For the below questions, please indicate4 which conditions have received a formal diagnosis for yourself or for your genetic relatives.
Breast Cancer*
Breast cancer details*
Leukemia*
Leukemia details*
Uterine/Vaginal Cancer*
Uterine/Vaginal Cancer Details*
Heart Disease*
Heart Disease Details*
Heart Murmur*
Heart Murmur Details*
High Blood Pressure*
High Blood Pressure Details*
Obesity*
Obesity Details*
Arthritis*
Arthritis Details*
Stroke*
Stroke Details*
Chemical Exposure*
Chemical Exposure Details*
Please enter any other conditions for you or your genetic relatives not listed above*

For the below questions, please indicate which conditions have received a formal diagnosis for yourself or for your genetic relatives.
Hospitalization for any mental health condition or crisis*
Who was hospitalized?*
Please explain the hospitalization*
Attempted Suicide*
Who attempted suicide?*
Please explain the attempted suicide*
Manic Depression, Bipolar Disorder or Schizophrenia?*
Who has Manic Depression, Bipolar Disorder, or Schizophrenia?*
Please explain the manic depression, bipolar disorder or schizophrenia*
Anxiety*
Who has anxiety?*
Please explain the anxiety*
Situational Depression*
Who has situational depression?*
Please explain the situational depression*
Learning disabilities*
Who has learning disabilities?*
Please explain the learning disabilities*
Attention Deficit Disorder or Attention Deficit Hyperactivity Disorder (ADD/ADHD)*
Who has ADD or ADHD?*
Please explain the ADD/ADHD*
Autism Spectrum Disorder*
Who has a form of autism?*
Please explain the autism spectrum disorder*
Eating disorders*
Who has an eating disorder?*
Please explain the eating disorder*
Obsessive Compulsive Disorder (OCD)*
Who has OCD?*
Please explain the OCD case*

What do you plan to tell your child(ren) about this pregnancy and child?*
Is there anything else you would like to tell the intended parent(s), or anything you think they should know?*
What qualities in your intended parent couple are most important to you?*
Would you be open to talking/meeting the intended parent(s) or their child?*

Step 1 of 16 - About You

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