First Name:
Last Name:
Mailing Address:
City:
State:	Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip Code:
Email Address:
Best Contact Phone Number:
Message O.K.?	Yes No
Second Contact Phone Number:
Message O.K.?	Yes No
How did you hear about us?
Date of birth:	January February March April May June July August September October November December   1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Ethnicity:
Height:	' "
Weight:
Hair
Natural Color:	Red Strawberry Blonde Blonde Dirty Blonde Light Brown Brown Dark Brown Black
Color at birth:	Red Strawberry Blonde Blonde Dirty Blonde Light Brown Brown Dark Brown Black
Eye color:	Black Blue Brown Green Hazel
Do you smoke?	Yes No
Do you drink, if so how often?
Are you adopted?	Yes No
Have you completed high school?	Yes No
Are you currently a college student, if so what is your major?	Yes No
Do you have a college degree? If so what was your major?	Yes No
Occupation:
Number of siblings:
Marital status:	Married Single In a relationship
Number of sexual partners in the last year:
Number of sexual partners in your lifetime:
Have you been an egg donor before?	Yes No
What type of birth control are you presently using?
Number of pregnancies:
Number of children:
When was your last pap smear?
What were the results?
Have you ever had an abnormal pap smear? If so, please explain:
Have you or a partner of yours ever been diagnosed with a sexually transmitted disease such as Chlamydia, Genital Herpes, Genital Warts, Gonorrhea, HIV or AIDS? If so please explain including the date of diagnoses and form of treatment:
Have you ever had surgery? If so, please explain:
Do you have any tattoos and/or body piercings? If so, when did you receive them?
Have you ever been incarcerated? If so, please explain:
Have you ever used a mind altering drug such as marijuana, cocaine, heroin, ecstasy, LSD or methamphetamines? If so, please explain which drug, frequency of use, and last date used:
Are you currently pregnant or breast feeding?	Yes No
Have you lived outside of the United States for more than 3 months since 1980?	Yes No
If yes, please give details on where you lived, which year(s) you lived there and for how long:
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