Egg donor interview

Munasolulahjoittajan lomake EN

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Personal Data

Last name

First names

Date of birth

Age

Street address

Post code

City/municipality

Email address

Phone number

Physical characteristics and ethnicity

Ethnic group: Finnish/something else, please specify

Height

Weight

About being a donor

Have you donated eggs before?

I have read the information related to egg donation on Ovumia's website and I am aware that if I am accepted as an egg donor, I will have to visit the clinic 3-4 times during the donation period. 

Yes

Menstrual cycle

Age of first menstruation

Duration of menstrual cycle (in days, from the first day of one period to the first day of the next)

Is your cycle regular?

Are you using any form of contraception?

Genital health

Have you had any genital diseases, such as infections, endometriosis, genital tumors, or other conditions? Please specify.

Pregnancy history

Number of pregnancies

Childbirths, years

Have you been previously treated for infertility? Where and what kinds of treatments?

State of health

Do you have any illnesses? If yes, which ones? (e.g., diabetes, hypertension, gastrointestinal disorders)

Have you had any surgeries?

Medication

Do you take medications regularly? If yes, please specify.

Stimulants

Do you use nicotine products? If yes, what and how much? If you quit, when?

Alcohol consumption per week/month (1 unit = 12 cl wine, 33 cl cider/beer, 4 cl spirits)

Do you use or have you ever used/experimented with drugs? If yes, what and when?

Illnesses and diseases in your immediate family

Does your family have the following diseases? Specify who: Self / Mother / Father / Sibling / Own Child / Grandparent

	mother	father	sibling	own child	grandparent
Cardiovascular diseases
Diabetes
Gastrointestinal diseases
Other internal organ diseases (liver, kidney)
Rheumatic or connective tissue diseases
Neurological diseases (MS, epilepsy, ALS)y
Mental health conditions (depression, bipolar disorder, schizophrenia)
Neurodevelopmental disorders (ADHD, Asperger, autism)
Congenital abnormalities (clubfoot, cleft lip/palate, scoliosis)
Other hereditary diseases
None of the above

Have you or your close relatives undergone chromosome analysis or testing for hereditary diseases? If yes, who and what was the result?

Somewhere else:

Other factors that may influence donation of eggs, and possible wishes or comments:

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By submitting this form, I consent to the storing of my patient data in Ovumia Oy’s register of patients.