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Introduction
Personal Bio
Education Information
Health / Reproductive History
Family / Genetic History


First Name:

Jaime

This donor is Available!
Donor #

77080

Medical History

Have you had any cosmetic reconstructive surgery?

No

Do you have any current or past medical problems?

No

Excess body or facial hair growth?

No

History of bleeding tendencies or bruising easily?

No

What is your blood type?

O+

When was your last HIV (AIDS) Test?

Mar, 2012

How many medications have been prescribed to you in the last 5 years?

1

Medications Prescribed in the Last 5 Years:

Medication Started        Medication Ended     Name of Medication     Reason for Prescription    

Sep, 2011

   

Dec 12, 2018

   

Minocycline

   

To keep skin clear

   
How many surgeries have you had in your lifetime?

0

Have you ever worn corrective lenses?

No

Have you ever had neck or back problems?

No

Have you ever been diagnosed with cancer?

No

Have you ever been diagnosed or suffered from asthma?

No

Have you ever been diagnosed or suffered from an irregular heartbeat?

No

Have you ever been diagnosed or suffered from any type of heart problem?

No

Have you ever suffered any type of head injury?

No

Have you ever been diagnosed or suffered from high blood pressure?

No

Have you ever suffered from migraine headaches?

No

Have you ever been diagnosed with a thyroid problem?

No

Have you ever experienced seizures or fits?

No

Have you ever been diagnosed with diabetes?

No

Have you ever been diagnosed with anemia?

No

Have you ever been diagnosed with Hepatitis B?

No

Have you ever been diagnosed with Hepatitis C?

No

Have you been tested as a carrier of any genetic disorder?

No

Psychological History

Do you have any mental health problems?

No

Does anyone in your family have any mental or emotional disorders?

No

Have you ever thought about committing suicide?

No

Have you ever attempted to commit suicide?

No

Have you ever intentionally and/or caused yourself physical harm?

No

Do you feel you were ever a victim of sexual, physical, or psychological abuse?

No

Have you ever induced vomiting or taken laxatives to lose weight or keep from gaining weight?

No

Reproductive History

History of no pregnancies despite sexual activity occurring without contraception for more than 6 months?

No

Have you ever participated in sexual intercourse?

No

Please indicate what type of birth control you are currently using.

Condoms, Birth Control Pills

Have you ever been diagnosed with PID (Pelvic Inflammatory Disease)?

No

Have you ever been diagnosed with or experienced genital warts or sores?

No

Have you ever been diagnosed with ovarian cysts?

No

Have you ever been diagnosed with uterine fibrosis?

No

Have you ever been diagnosed with herpes?

No

Have you ever been diagnosed with gonorrhea?

No

Have you ever been diagnosed with syphilis?

No

How many abortions have you had?

0

How many miscarriages have you had?

0

How many stillbirths have you had?

0

Previous Cycles:

Donation     Number of Eggs Retrieved     Number of Embryos Created     Number of Embryos Transferred     Number of Embryos Frozen     Pregnancy Outcome    

1

   

24

   

8

   

4

   

4

   

Positive

   

2

   

20

   

5

   

3

   

2

   

Positive

   
Have you ever had an abortion because of abnormal fetal development?

No

Have you ever undergone any fertility treatments to become pregnant?

No

Do you have a menstrual cycle every month?

Yes

How many days are between the first day of your period to the first day of your next period?

28

Social History

Do you smoke or use tobacco in any form?

No

Have you ever had problems with drugs or alcohol?

No

Have you ever been in a substance abuse program?

No

Have you ever taken recreational drugs, including marijuana?

Yes

If yes, please explain:

One time in high school.

What is your sexual orientation?

Heterosexual

How many sexual partners have you had in the past year?

1

Are you currently sexually active?

Yes