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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:
What is the closest major city to where you live?
Email Address:
Verify 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
Age:
Ethnicity:
Height:
'
"
Weight:
Natural Hair Color:
Red
Strawberry Blonde
Blonde
Dirty Blonde
Light Brown
Brown
Dark Brown
Black
Hair Color as a Child:
Red
Strawberry Blonde
Blonde
Dirty Blonde
Light Brown
Brown
Dark Brown
Black
Eye color:
Black
Blue
Brown
Green
Hazel
Do you smoke?
Yes
No
Have you smoked Cigarettes in the past 2 years?
Yes
No
Are you willing to take a nicotine screening test?
Yes
No
Do you drink, if so how often?
Are you adopted?
Yes
No
If so, will you be able to provide any health history for at least one side of your biological family?
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
Would you be willing to submit copies of your college transcripts if requested
Yes
No
Does Not Apply
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?
Are you presently using the birth control Depo Prevera (the shot) or have you used Depo Prevera in the past 12 months?
Yes
No
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:
I understand that a current pap (within 12 months) is required and that Family Creations will be asking to receive a copy of my most recent pap.
Click this check box if you agree to send Family Creations a copy of your recent pap.
Have your or your partner tested positive for Chlamydia in the past 12 months?
Yes
No
Have your or your partner tested positive for Gonorrhea in the past 12 months?
Yes
No
Have your or your partner tested positive for Syphilis in the past 12 months?
Yes
No
Have you or your partner tested positive for HIV/AIDS?
Yes
No
Please clarify your previous response
I have been diagnosed with HIV/AIDS
My Partner has been diagnosed with HIV/AIDS
Neither my partner nor I have been diagnosed with HIV/AIDS
Have you ever had surgery?
If so, please explain:
Have you ever been incarcerated?
Yes
No
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:
Have you used any illegal drugs in the past 12 months?
Yes
No
Are you willing to take a drug test?
Yes
No
Are you currently pregnant or breast feeding?
Yes
No
Have you traveled to a country in the past 12 months where you were advised / required to receive a malaria vaccine?
Yes
No
Have you traveled to Iraq in the past 12 months?
Yes
No
Have you lived in any of the following countries for 5 or more consecutive years?
Albania, Austria, Belgium, Bosnia / Herzegovina, Bulgaria, Croatia, Czech Republic, Denmark, Finland, France, Germany, Greece, Hungary, Ireland, Italy, Kosovo (Federal Republic of Yugoslavia), Liechtenstein, Luxembourg, Macedonia, Montenegro (Federal Republic of Yugoslavia), Netherlands (Holland), Norway, Poland Portugal, Romania, Serbia (Federal Republic of Yugoslavia), Slovak Republic (Slovakia), Slovenia, Spain, Sweden, Switzerland, Turkey, Yugoslavia (Federal Republic includes Kosovo, Montenegro, and Serbia)
Yes
No
Have you lived in or visited any of the following countries for 3 or more months between 1980 and 1986?
Channel Islands, England, Falkland Islands, Gibraltar, Isle of Man, Northern Ireland, Scotland or Wales
Yes
No
Have you received a tattoo in the past 12 months?
Yes
No
Have you received a piercing in the past 12 months?
Yes
No
Are you or any of your biological family members registered with any Native American tribes?
Yes
No
Are you currently enlisted in the Military?
Yes
No
Please upload a recent photograph of yourself. Applications with photographs submitted will be processed faster.
I agree that I represent that all written representations and information provided and/or to be provided to Family Creations, LLC, and any professional, psychologist, physician, physician's assistant, nurse, attorney, or designee of Family Creations, are true, correct and complete.
Click this check box if you agree
