Donation History
Yes, I have donated
First time donor
Name
*
First Name
Last Name
Email
*
Phone
*
(###)
###
####
State / Country
*
Date of Birth
MM
DD
YYYY
Blood Type
Rh Factor
Height
Weight
Natural Eye Color
Natural Hair Color
Hair Texture
Skin Tone
Your Ethnicity/ Origin
Jewish Ancestry
Astrological Sign
Aries (March 21 - April 19)
Taurus (April 20 - May 20)
Gemini (May 21 - June 20)
Cancer (June 21 - July 22)
Leo (July 23 - August 22)
Virgo (August 23 - September 22)
Libra (September 23 - October 22)
Scorpio (October 23 - November 21)
Sagittarius (November 22 - December 21)
Capricorn (December 22 - January 19)
Aquarius (January 20 - February 18)
Pisces (February 19 - March 20)
Personality Traits
Father's Natural Eye Color
Father's Natural Hair Color
Mother's Natural Eye Color
Mother's Natural Hair Color
Education Level
ACT / SAT Score
High School Graduated / GPA
College Graduated / GPA
College Major / Degree
Favorite Subject
History & Social
Art & Music
Technology
Medicine
English Literature
Science
Mathematics
Computer Science
Sports
Hobbies
Talents
Have or had any pet(s)?
Dog
Cat
Horse
Fish
Reptiles
Other small animal
Have you done any traveling to another country?
Your favorite foods
Which characteristics do you think is most important?
Personal Goal
Community Service
Fame
Rewarding Career
Further Education
To Be Happy
Marriage/Family
Recognition
To Help People
Financial Security
Is your health condition generally healthy?
Are you currently taking any medication(s)?
Are you under a doctor's care?
Do you have any emotional or depression problem?
Do you were corrective lenses?
Do you have normal hearing?
Have you ever taken any growth hormones?
Have you ever taken any non-prescribed steoids?
Have you had any plastic surgery?
Have you ever done any genetic counseling or screening?
Do you or any family members have a history of drug abuse?
*
Do you or any family members have a history of alcohol abuse?
*
Have you or any of your family member have any of the following conditions?
*
Allergy problem as: Medication Allergy, Food Allergy, Sinusitis Rhinitis
Endocrine problem as: Diabetes Mellitus, Hypoglycemia, Hyperthyroidism Hyperparathyroidism
Blood & Circulation problem as: Anemia, Hemophilia Leukemia, Lymphoma
Eye/Ear/Nose/Throat problem as Cataracts, Malformation, Macular Degeneration, Joint Dysfunction
Cardiovascular problem as: Angina, Heart Failure, Hypertension, Stroke
Digestion problem as: Cirrhosis, Hepatitis, Viral, Pancreatitis, Gallbladder Disease
Skin problem as: Acne, Erythema, Hirsutism, Psoriasis
Musculoskeletal problem as: Gout, Lupus, Arthritis, Osteoporosis
Psychology problem as: Alcoholism, Dementia, Depression, PTSD
Reproductive problem as: PCOS, Ovarian Cysts, Vaginitis, Endometriosis
Any known cancer condition as: Breast Cancer, Cervical Cancer, Colorectal Cancer, Skin Cancer
How old were you at your first menstrual cycle?
When was your last menstrual period?
MM
DD
YYYY
How long is your menstrual period?
How many days between periods?
Do you have regular cycle?
Your method of birth control?
Use Birth Control Pill
Use Contraceptive Ring
No, I have never used birth control pill or ring
When was your last PAP SMEAR?
MM
DD
YYYY
Was the result normal?
Have you ever been treated for a STI?
Have you ever injected non therapeutic drugs?
Have you had any abortion?
Have you had any miscarriage?
Have you had any ectopic pregnancy?
Have you been told you are infertile?
Have anyone in your family had infertility problems?
Do you have children of your own?
