Pre-Screening Questionaire

Pre-Screening Questionaire
Thank you for considering becoming an egg donor for stem cell research. Answering the questions below will help us determine if you qualify for this important research program. If you are selected, a medical professional will get in touch with you to schedule a more extensive screening process, including a blood test.
The information you provide will be handled in the strictest confidence and will only be used to determine your eligibility for this stem cell research program. The information will not be shared and will only be seen by a medical professional at the California Center for Reproductive Medicine (CACRM).
Full Name*

First NameLast Name
E-mail*
Phone Number*

Area CodePhone Number
Zip Code*
Are you between the ages of 21 and 29 ?

YesNo
Are you a smoker?

NoYes
Do you have a BMI of less than 30?

YesNo
Calculate your BMI
Do you have a history of infertility?

YesNoNot sure.
Do you excercise regularly?
If you have been an egg donor before, please provide the clinic name:
Please add any other comments that you think may be relevant:
Should be Empty: