Egg donor health record

Personal information

Address *

Hobbies

Marital status, length of relationship *

I have reviewed the information regarding egg donation on the Nova Vita clinic website and am aware that, as an egg donor, I will need to visit the clinic 3–4 times during the donation period. *

Yes
No

Why did you decide to become an egg donor? *

May the treating physician review your medical records before your appointment? *

Yes
No

Please provide justification. *

Your personal characteristics

Eye color *

Hair color *

Skin color *

Height *

Body weight/body mass index *

Medical history

Have you donated eggs before? *

No
Yes

So when and where? *

How would you rate your current health? *

I am healthy
Other

Then please specify. *

Have you received fertility treatment? *

No
Yes

Then why? *

Are you exposed to radiation or chemicals at work? *

No
Yes

Then which ones? *

Do you take medication on a daily basis? *

No
Yes

Then which ones? *

Have you used drugs in the past? Do you currently use them? *

No
Yes

Then which ones? When was the last time? *

Do you currently smoke? *

No
Yes

Then how many cigarettes per day?

Do you drink alcohol, and if so, how much? *

No
Yes

Then how much? *

At what age did your first period start? *

Length of your cycle? (from the first day of one period to the first day of the next) *

Have you given birth? Are your children healthy? *

No
Yes

Then when? *

Date of your last period? *

Duration of bleeding (from the first day of menstruation to the last day of bleeding) *

Have you given birth? Are your children healthy? *

No
Yes

How many? Years? *

Have you ever had an abortion? *

No
Yes

How many? Years? *

Have you ever had a spontaneous miscarriage? *

No
Yes

Then how many? Years? *

Have you had any ectopic pregnancies? *

No
Yes

Then how many? Years? *

What method of contraception are you currently using? *

Then please clarify. *

Have you ever had vaginal intercourse? *

Yes
No

Have you ever had unprotected sex (without a condom)? *

No
Yes

Then when? *

Have you lived or traveled abroad in the past year? *

No
Yes

Then where? *

Last PAP test (when? Was the result normal?) *

Past or current illnesses (e.g., frequent respiratory infections, tonsillitis, asthma, tuberculosis, etc.)

Do you have any allergies? *

No
Yes

Then for what? *

Have you been diagnosed with any of the following sexually transmitted diseases: chlamydia, gonorrhea, trichomoniasis, syphilis, genital herpes, etc.? *

Ei
Jah

Which one and when? *

Gynecological conditions: endometriosis, uterine, ovarian, or vaginal conditions? *

No
Yes

Which one and when? *

Infectious diseases: HIV, hepatitis B, hepatitis C, etc.? *

No
Yes

Which one and when? *

Nervous system disorders: migraine, cluster headache, sleep disorders, etc.? *

No
Yes

Which one and when? *

Skin conditions: psoriasis, rashes, dermatitis, scleroderma, etc.? *

No
Yes

Which one and when? *

Respiratory diseases: frequent respiratory infections, tonsillitis, asthma, tuberculosis, etc.? *

No
Yes

Which one and when? *

Heart and circulatory system diseases: high blood pressure, thrombophilia, anemia, coagulation disorders, etc.? *

No
Yes

Which one and when? *

Kidney and urinary tract diseases: pyelonephritis, cystitis, etc.? *

No
Yes

Which one and when? *

Liver and biliary tract diseases: cirrhosis, jaundice, etc.? *

No
Yes

Which one and when? *

Digestive system diseases: intestinal diseases, gastritis, irritable bowel syndrome, etc. *

No
Yes

Which one and when? *

Endocrine diseases: diabetes, thyroid disorders, etc.? *

No
Yes

Which one and when?

Sensory organ disorders: nearsightedness, hearing loss, etc.? *

No
Yes

Which one and when? *

Skeletal disorders: scoliosis, osteoporosis, fractures, etc.? *

No
Yes

Which one and when? *

Mental disorders: depression, schizophrenia, mania, bipolar disorder, ATH, etc.? *

No
Yes

Which one and when? *

Autoimmune diseases: multiple sclerosis, arthritis, rheumatoid arthritis, lupus, etc.? *

No
Yes

Which one and when? *

Other conditions: celiac disease (gluten intolerance), lactose intolerance? *

No
Yes

Then which one and when? *

Have you had any surgeries? *

No
Yes

Then when? Which ones? *

History of hereditary diseases and developmental disorders in the family

Do you have any sisters or brothers? *

No
Yes

If so, do they have children? Are they and their children healthy? *

Do you have uncles and aunts? *

No
Yes

If so, do they have children? Are they and their children healthy? *

Have there been stillbirths in your family? *

No
Yes

Then who? *

Are there any vascular diseases in your family? (e.g., hemophilia, hypertension) *

No
Yes

Then who and which ones? *

Is there a history of nerve and muscle disorders in your family (e.g., muscular dystrophy)? *

No
Yes

Then who and which ones? *

Is there a history of kidney disease in your family? (e.g., polycystic kidneys, congenital kidney damage) *

No
Yes

Then who and which ones? *

Is there a history of eye diseases in your family? (e.g., retinitis) *

No
Yes

Then who and which ones? *

Is there a history of bone disorders in your family? (e.g., osteogenesis imperfecta, skeletal malformations in newborns) *

No
Yes

Then who and which ones? *

Are there any other metabolic disorders in your family? (e.g., alpha-1-antitrypsin deficiency, INCL, AGU, hemochromatosis, hereditary hypercholesterolemia, cystic fibrosis) *

No
Yes

Then who and which ones? *

Is there a history of intellectual disability in your family? (e.g., Down syndrome, early-onset dementia (at ages 40–50), early-onset Alzheimer’s, autism, fragile X syndrome) *

No
Yes

Then who and which ones? *

Is there anyone in your family with a physical disability? (e.g., clubfoot, hip dislocation, cleft lip and palate, congenital heart defects, neural tube defects, deafness) *

No
Yes

Then who and which ones? *

Is there a history of diabetes in your family? *

No
Yes

If so, who and since when (which year)? *

Is there a history of the following conditions in your family: schizophrenia, manic depression, bipolar disorder, etc.? *

No
Yes

If so, who and which ones? *

Where did you hear about the Ovumia Tallinn Clinic? *

Other *

If we wish to contact you, what would be the most convenient way? *

Other *

I have read and agree to the privacy policy of Ovumia Tallinn/AS Nova Vita Clinic *

I confirm that all of the above information is correct. If my contact information (name, address, phone number, email) changes, I will notify the Clinic immediately. *

Egg donor health record

Thank you for wanting to help

Personal information

Your personal characteristics

Medical history

Past or current illnesses (e.g., frequent respiratory infections, tonsillitis, asthma, tuberculosis, etc.)

History of hereditary diseases and developmental disorders in the family

Thank you for reaching out to us.