1. What is your FIRST name?
 
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2. Are you a US Citizen or permanent resident?
 
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3. Are you eligible to work in the United States?
 
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4. What radio station do you listen to the most?
 
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5. How do you like to stream your music?
 
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6. What is your primary phone number that will accept messages if not answered?
 
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7. Please use Google Maps or MapQuest and determine your driving distance to our office. Address: 9819 North 95th Street, Scottsdale, AZ 85258
 
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8. Would you be comfortable giving yourself daily injections of medication?
 
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9. What is your date of birth?
 
   
10. What is your height in feet and inches?
 
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11. How much do you currently weigh?
 
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12. Were you adopted?
 
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If yes, do you have contact with your biological parents?
13. What ethnicity do you consider yourself to be? (Example: Caucasian, Asian, Welsh, Hispanic, African American, etc)
 
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If other, please explain
14. Have you ever been tested as a carrier for Thallassemia? Results?
 
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15. Have you been tested as a carrier of sickle cell disease? Results?
 
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16. What is your highest educational achievement level?
 
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17. Did you have any learning disabilities or weaknesses in school?
 
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If yes, please give all details
18. Is your work schedule flexible?
 
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19. How many times have you donated your eggs?
 
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20. Have you applied or been screened to be an egg donor before?
 
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21. Do you smoke?
 
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If yes, how many cigarettes per day?
22. Are you currently enrolled in another egg donor program?
 
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23. At what age did you have your first period?
 
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24. What is the number of days between periods? (Count start of flow to start of next flow)
 
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25. Is there a history of infertility in your family, please specify:
 
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If yes, please explain.
26. What method of Birth Control do you currently use?
 














If "Other", please explain.
27. How many sexual partners have you had in the past 12 months?
 
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28. Have you ever injected drugs or had a sexual partner who did so?
 
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29. In the past three years have you been outside the USA or Canada? Please explain where and when
 
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If yes, please list the full date of when (MM/DD/YY) and where. If no, type NA
30. In the past three years have you traveled to Mexico? If so, please specify region
 
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If yes, please list the full date of when (MM/DD/YY) and where. If no, type NA
31. Do you plan on traveling out of country within the next 6-8 months?
 
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If yes, please list the full date of when (MM/DD/YY) and where. If no, type NA
32. In the past 12 months have you had a blood transfusion?
 
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33. In the past 12 months have you had a tattoo?
 
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You MUST state business name where tattoo was performed
34. In the past 12 months have you had any ear/body piercing?
 
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You MUST state business name where body piercing was performed
35. What are reasons for wanting to donate your eggs?
 
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36. How did you hear about becoming an egg donor?
 
Initial Interest From ... Name or Organization
Friend:  
Another Donor:  
A Patient from AFC:  
Advertisement:  
Internet Inquiry:  
37. What is your email address for communication with you regarding your pre-screen application?
   
38. What is your preferred password for future login reference?
   (6-20 characters with 4 or more letters and 1 or more numbers)  
39. Verify your password.
   

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