Questionnaire for egg donors

Please answer the questions below by ticking the box. Correct answers will affect the couple who will receive your eggs. All health information will be treated confidentially.

Questionnaire for egg donors

Have you ever:

Have you had allergies (e.g. asthma, hay fever, hypersensitivity to medication)?
Had heart problems?
Had kidney disease?
Had diabetes?
Had liver inflammation?
Had epilepsy (febrile seizures) after puberty?
Had any serious illnesses?
Had any other uncommon illnesses?
Do you suffer from chronic diseases (metabolic diseases, diabetes, mental disorders?
Do you use any medication?
Do you use natural remedies?
The doctor will also ask about these answers during the interview.

Hereditary disorders – genetics Have you or someone in your family (children, parents, grandparents or siblings) suffered from one or more of the following conditions:

Are there any hereditary diseases in your family?
Are there any chromosomal diseases in your family, e.g. mongolism?
Are there people with intellectual disabilities in your family?
Are there any neurological or muscular diseases in your family?
E.g. dementia, Alzheimer’s, epilepsy, muscular dystrophy?
Is there cancer in your family?
Are there any cases of sudden death in your family? (under the age of 50).
Is there any congenital metabolic disease in your family?
Is there kidney disease in your family?
Do you or anyone in your family have diabetes?
Do you have a gastrointestinal disease (e.g. Crohn’s disease)?
Do you or anyone in your family have Cystic Fibrosis (hereditary lung disease)?
Is there severe visual or hearing impairment in your family?
Are there any skeletal disorders in your family, such as dwarfism or facial bone deformities?
Do you have – or have you had a child with congenital malformations?
E.g. cleft lip and palate, clubfoot, spina bifida, congenital heart defect or other?
Do you have a psychiatric diagnosis, e.g. schizophrenia or bipolar disorder?
Are there any psychiatric illnesses in your immediate family?
The doctor will also ask about these answers during the consultation.

Previous pregnancies

Have you given birth before?
Have you given birth normally?
Or by caesarean section?
Have you been pregnant with twins?
Have you had an involuntary miscarriage?
Do your children live with you?
Have you chosen to have an abortion?
Have you had an ectopic pregnancy?

Information about menstrual conditions, pelvic diseases and cohabitation

Are your periods regular?

Have you within the last 6 months:

Had prolonged periods of fever?
Had unintentional weight loss?
Been pregnant?
Been outside Europe?
Had a blood transfusion?
Been pierced in the ears or elsewhere (piercing)?
Had a tattoo?
Had acupuncture performed by a non-authorised healthcare professional?
The doctor will also ask about these answers during the consultation.

Have you within the last 12 months:

Had unprotected intercourse with someone other than your regular partner?

Other information

Were you born or raised in an area where malaria is present?
Could you have been exposed to HIV?
Do you feel completely healthy?
Have you previously donated eggs at other clinics?
Have you been in contact with other clinics to donate eggs?
Can your GP be contacted if in doubt?

Lifestyle

Do you smoke?
Do you exercise?

Summer holiday 2025

The clinic is closed

for the summer holidays

from 12th – 27th of July

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