1. Step Name Surname Birth Date Height (cm) : Weight (Kg) : Place of birth city Place of birth country Blood type A B AB 0 RH - RH + Skin color Fair Medium Dark Ebony Eye Color Black Brown Green Blue Hazel Other Glasses Miyop Hipermetrop Astigmat Number : Natural Hair Color Black Brown Blonde Red Other Hair Type Straight Wavy Curly Thin Thick Are You Predominantly? Right Hand Left Hand Education Literate Grammar School Middle School High School University PhD & Above Marital Status Single, no sexual partner Single, has sexual partner Engaged Married Comitted to life partner Separated or divorced Religion : Muslim Christian Jewish Budist Other In the event that I become a donor, I will be available after the following date: Now At a future date : (DD/MM/YYYY) 2. Step Work History Homemaker I work full time I work part time Currently unemployed Please list the kind of work you have done according to their dates : What languages do you speak? (Check all that apply) Turkish English German Other...Please type : Do you have any special skills or hobies? Please list them below : Smoking I currently smoke cigarettes per day I quit smoking I haven't smoked for ....years : I never smoked Alcohol I always drink alcohol I rarely drink alcohol I never drink alcohol Drug Usage I currently use illegal drugs I used to use illegal drugs but I quit years ago I am currently using over legal drugs I use drugs for therapeutic purposes, please clarify : 3. Step Sexual Behavior I have and still do work as a prostitute I have had.... Sexual partners : I have contracted sexually transmitted diseases. Please clarify I am currently in a monogomous relationship I have never engaged in sexual interourse Legal Background I have never had any legal trouble Legal Background I have had legal trouble. If yes, then please explain the kind of legal trouble you have had : Psychocological History Have you ever been diagnosed as having depression? No Yes, please explain : Have you ever used drugs to treat a psychological disorder? No Yes, please explain : Have you ever been diagnosed as having one of the following (Please check all that apply) : Depression Schizophrenia Manic depression Obsessive complusive disorder Mania Other, please explain : : Anorexia or bulimia Do you have any allergies that you are awere of? No Yes, please explain : Have you ever experienced side effects from general anesthesia? No Yes, please explain : 4. Step Menstrual History The number of days between one period and the next is ... Days : The number of days that your period last is .... Days : Are your periods regular? Yes No How would you describe your menstrual flow? Light Moderate Heavy Very Heavy Pregnancy History How many times have you been pregnant (0-?) : How many times have you given birth (0-?) : Were there any complications during the pregnancy or delivery? If yes, please explain : Have you had a Pap Smear in past year? No Yes Are your Pap Smear result normal? No Yes Have you had a blood transfusion in the last two years? No Yes Have you had a tattoo done in the past 5 years? No Yes Are you currently on the donor list of another center? No Yes Have you ever donated eggs before? No Yes Year : Number of eggs retrieved: 5. Step Address Email GSM ID How did you learn about our program? Advertisements Internet Friend or another donor : 3+4=? (Please type the result below)
