Questionnaire for Potential Egg Donors

In order for us to process your application, please provide the following information which is required to conform with the legal requirements for donation. We appreciate some questions are of an extremely personal nature but please be assured your answers are confidential. We strongly recommend you read the egg donation information booklet before proceeding.

I am living in the United Kingdom, live within two hours of Southampton and I am aged between 18 and 35..

YesNo

Please note we are based in Southampton, due to the number of appointments required during the donation process, we recommend a maximum travelling time of 2 hours. If you live outside this range and would like to investigate clinics closer to home you may find the link below useful:

Fertility clinic search | HFEA

First Name

Surname

Date of Birth

Age

Ethnicity

Country of Birth

Email address

Phone Number

Address

Postcode

Where did you hear about Complete Fertility Centre

In a few words tell us about your motivation for donating your eggs

Are you adopted?

Are you donor-conceived?

Do you know your biological mother and father?

Ethnicity of biological mother

Ethnicity of biological father

Ethnicity of biological maternal grandmother

Ethnicity of biological maternal grandfather

Ethnicity of biological paternal grandmother

Ethnicity of biological paternal grandfather

Are you Jewish or of Jewish descent?

Do you consider yourself to be fit and healthy?

Have you been abroad in the last 12 months?

If yes what countries did you visit?

Do you or anyone in your immediate family (parents, grandparents, siblings, offspring) suffer from a serious mental or physical illness or medical condition? E.g. diabetes, epilepsy.

If yes please give details

Do you or anyone in your immediate family (parents, siblings, offspring, grandparents) have a genetic or inherited medical illness or disorder? E.g. cleft lip, Huntington’s disease, cystic fibrosis

If yes, please give details:

Do you or anyone in your immediate family (parents, siblings, offspring, grandparents) suffer from or have ever suffered from a form of cancer? If yes, please list type of cancer and age of diagnosis (if known)

If yes please give details

Are you on any medication?

If yes please give details

Do you take or have you ever taken Pre-Exposure Prophylaxis (PrEP)?

Are you currently using contraception?

If yes, please state type of contraception

(When not on contraception) do you have regular periods?

Please give cycle details:

Have you ever had a smear, internal examination or ultrasound?

During treatment you will be required to have internal vaginal ultrasound scans and examinations it is important you are comfortable with this procedure. Would you be happy to consent to these procedures?

Have you ever been diagnosed with any gynaecological disorders e.g. polycystic ovaries, endometriosis?

If yes, please give details

Have you ever had any abdominal surgery?

If yes, please give details

Do you have, or have you ever had any sexually transmitted diseases?

If yes, please give details

Do you or have you ever engaged in anal sex?

Do you smoke?

Do you take any illegal drugs?

If yes please give details

Have you ever been convicted of a criminal offence?

If yes please give details

Have you ever donated or applied to donate your eggs at another HFEA licensed centre?

If yes please give details

Have you ever donated or applied to donate your eggs in any other context in the UK or abroad?

If yes please give details

What is your height in metres?

What is your weight in kilograms?

BMI

Have you ever been pregnant?

Do you have any children?

Are you able to provide photo identification (passport or driving licence)?

GP Name

GP Surgery

I confirm that I have answered this questionnaire truthfully and to the best of my knowledge:

Yes

Signature

What happens next?
Your completed questionnaire will be reviewed by the donor coordinator. We may contact you for more information regarding your answers. If your answers show that you meet the criteria to become an egg donor you will be invited to attend the clinic for an initial appointment. Our preferred methods of contact are telephone and email so please ensure you have given these details at the start of this form. We will not contact your GP at this stage.

Sorry

Based on your responses we are unable to continue processing your application.