Donor Application Form Date  
 
 Name Surname  
 Birthdate    (DD/MM/YY)    
 Address  
     
 City Zip Code  
 Home Phone   Cell Phone   +90 5XX XXX XX XX
 E-Mail      
         
 Place of Birth        
 City Country  
         
 How did you learn about our program?
 Friends or another donor   
 Advertisements    
 Internet    
         
 In the event that I become a donor, Iwill be available after the following date :
Now At a future date>>  After (DD/MM/YY)
 
         
 Marital Status        
Single, no sexual partner Engaged
Single, has sexual partner Married
Separated or divorced Comitted to life partner
         
 Religion        
Muslim Christian Jewish
Budist Other    
         
 Blood Type A B AB 0        Rh + -  
         
 Physical Characteristics
 Height cm Weight
 Eye Color Black Brown Green     Blue Hazel Other
 Natural Hair Black Brown Blonde Red   Other
 Hair Texture
Straight Wavy Curly   Thin Thick
 Skin Color Fair   Medium    Dark   Ebony  
         
 Do you wear eye glasses ?      
Yes If yes then what is the number on your prescription
Miyop Hipermetrop Astigmat
No    
         
 Are you predominantly      
Right Handed Left Handed
         
         
 Educational Background      
Literate Middle School University Degree
Grammar School High School Degree

PhD and Above

         
 Work History      
Homemaker I work full time
Currently unemployed I work part time
 Please list the kind of work you have done according to their dates
         
 What languages do you speak ? (Check all that apply)  
Turkish English German Other...  
         
 Do you have any special skills or hobies ? Please list them below.
         
 Habits        
 Smoking        
I currently smoke   cigarettes per day
I quit smoking I haven't smoked for  years
I never smoked    
         
 Alcohol        
I always drink alcohol    
I rarely drink alcohol      
I never drink alcohol    
         
 Drug Usage        
I currently use illegal drugs    
I used to use illegal drugs but I quit years ago
I am currently using over legal drugs    
I use drugs for therapeutic purposes,Please clarify>
         
 Sexual Behavior      
I have and still do work as a prostitute    
I have had sexual partners
I have contracted sexually transmitted diseases.Please Clarifiy
I am currently in a monogomous relationship    
I have never engaged in sexual intercourse    
         
 Legal Background      
I have never had any legal trouble
I have had legal trouble.If yes, then please explain the kind of legal trouble you have had  
         
 Psychological History      
 Have you ever been diagnosed as having depression
No    
Yes Please explain
         
 Have you ever used drugs to treat a psychological disorder ?
No    
Yes Please explain
         
 Have you ever been diagnosed as having one of the following: (Please check all that apply)
Depression Manic depression Mania
Scgşzıogrebşa Osessive Complulsive disorder Anorexia or Bulimia
Other.Please explain
         
 Do you have any allergies that you are awere of ?
No    
Yes Please explain
         
 Have you ever experienced side effects from general anesthesia ?
No    
Yes Please explain
         
 Menstrual history      
The number of days between one period and the next is days  
The nuımber of days that your period lasts is days
Are your periods regular ? Yes       No
 How would you describe your menstrual flow ?  
Light  Moderate Heavy Very Heavy
         
 Pregnany History      
How many times have you been pregnant (0-?)     
How many times have you given birth(0-?) 
Were there any complications during the pregnancy or delivery? If yes , please explain >
         
 Have you had a PAP SMEAR in past year ?
No
Yes
         
 Is my Pap Smear result normal?
No
Yes
         
 Have you had a blood transfusion in the last two years ?
No
Yes
         
Have you had a tattoo done in the past 5 years ?
No
Yes
         
Are you currently on the donor list of another center ?
No
Yes
         
Have you ever donated eggs before
No
Yes->Year> , number of eggs retrieved