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We love what we do and it shows in the way we work with you.

PLEASE READ THE INSTRUCTIONS AND ANSWER ALL OF THE QUESTIONS COMPLETELY.

Please upload a photo along with your application. All donors must have graduated from or currently be attending college or university.

Donors must live in the San Francisco Bay Area, or within one to two hours' drive of San Francisco. We only work with local fertility clinics and local donors.

IMPORTANT:
You CANNOT be a donor if you are using any of the following methods of birth control:
- Injections (Depo-Provera)
- Implant (Nexplanon)
- Hormonal IUD (Mirena)
(You would need to switch your form of birth control to be able to donate.)

The forms of birth control that are compatible with donating are:
- Oral birth control pills
- Non-hormonal IUD (Paragard)
- Condoms

How did you find San Francisco Donor Network?

Name:

(first name only, if you prefer)

City of residence:

Phone number:

Best times to reach you:

Email address:

Preferred method of communication:

Age:

Date of birth:

Height:

Weight:

Hair color:

Eye color:

Ethnicity:

(ex: Caucasian)

Ethnic background:

(ex: French and German)

Marital status:

Number of pregnancies:

Date of most recent pregnancy:

Number of children:

Number of miscarriages:

Current method of birth control:

Are your periods regular?

How long is your monthly cycle (how long between periods)?

For the following questions if the answer is "yes", please explain.

Did your mother take diethylstilbestrol (DES) or any other prescription drugs that you know of while she was pregnant with you?

If the answer is "yes", please explain.

Have you ever been diagnosed with or treated for Attention Deficit Disorder (ADD), Attention Deficit and Hyperactivity Disorder (ADHD), Asperger's, autism, or as "on the spectrum?"

If the answer is "yes", please explain.

Do you have any chronic medical condition, such as asthma, diabetes, hypothyroidism, lupus, serious allergies, or any others?

If the answer is "yes", please explain.

Have you ever been hospitalized?

If the answer is "yes", please explain.

Have you ever been treated for a sexually transmitted disease, including herpes, chlamydia, etc.?

If the answer is "yes", please explain.

Have you ever been treated for a psychiatric disorder? (This does not include personal growth type therapy.)

If the answer is "yes", please explain.

Have you ever been employed in an area where you were exposed to toxic chemicals, lead products, or radiation?

If the answer is "yes", please explain.

Do you use any drugs other than small amounts of alcohol or marijuana?

If the answer is "yes", please explain.

Are you currently taking any medications?

If so, please indicate what they are and for what purpose they are taken.

Do you use glasses or contact lenses?

If so, since what age have you worn glasses? Do you know what your visual defect is?

Have you experienced any learning disability?

If the answer is "yes", please explain.

Do you have any allergies to drugs, foods, or anything else?

If the answer is "yes", please explain.

Have you donated previously?

If so, where and when?

Have you spent 3 or more consecutive months anywhere in the United Kingdom between 1980 and 1996?

If so, when and where?

Have you received a blood transfusion within the last year?

If so, when?

Do you currently have health insurance?

(a lack of health insurance will not disqualify you)

Have you been in any of the countries listed below for a cumulative 6 months since 1996?

Belgium
Germany
Greece
Italy
Netherlands
Portugal
Spain
Turkey

Have you lived in any of the countries listed below for a cumulative 5 years?

Albania
Austria
Bosnia-Herzegovina
Bulgaria
Croatia
Czech Republic
Denmark
Finland
France
Hungary
Ireland
Liechtenstein
Luxembourg
Macedonia
Norway
Poland
Rumania
Serbia-Montenegro
Slovakia
Slovenia
Switzerland

Family Health History

PLEASE READ CAREFULLY

For this section the word “family” refers to you and your immediate family, grandparents, aunts, uncles, great aunts, great uncles, and cousins.

For each of the following relatives, please state their age now if alive, or their age at the time of their death. If they are deceased, please indicate the cause of death.

If you do not have the information, please obtain it before sending in your application. Incomplete applications cannot be processed.

Mother:

Current Age (or age at time of death):

Cause of death:

Maternal Grandmother

Current Age (or age at time of death):

Cause of death:

Maternal Grandfather:

Current Age (or age at time of death):

Cause of death:

Father:

Current Age (or age at time of death):

Cause of death:

Paternal Grandmother:

Current Age (or age at time of death):

Cause of death:

Paternal Grandfather:

Current Age (or age at time of death):

Cause of death:

Aunts and Uncles: (Please list their current ages if living. If deceased, list their age at death, and cause of death.)

Siblings: (Please list their current ages if living. If deceased, list their age at death, and cause of death.)

If you know that any of your great grandparents, great aunts or uncles lived beyond the age of 80, please list their age at the time of their death.

Is there anyone in your family that died in infancy or childhood?

If the answer is "yes", please explain.

Has any member of your family ever been born with any birth defect or illness, hereditary or congenital?

If the answer is "yes", please state which family member and explain.

Has anyone in your family experience any neuromuscular disorder such as Parkinson’s, ALS, multiple sclerosis, etc.?

If the answer is "yes", please state which family member and at approx. what age they were diagnosed.

Has anyone in your family experienced any learning disability, autism or Asperger's?

If the answer is "yes", please state which family member and at approx. what age they were diagnosed.

Has anyone in your family experienced any metabolic disorder such as diabetes, hypothyroidism, etc.?

If the answer is "yes", please state which family member and at approx. what age they were diagnosed.

Has anyone in your family experienced any type of cancer?

If so, please state at what age he or she was diagnosed, what type of cancer it was, and what was the outcome.

Has anyone in your family experienced a stroke, a heart attack, high blood pressure, diabetes, or Alzheimer’s?

If the answer is "yes", please state what the condition is, which relative has it, and approximately at what age their condition was discovered or diagnosed.

Are there any other diseases that have been experienced by anyone in your family?

If the answer is "yes", please state which family member and at approx. what age they were diagnosed.

Is there any history of alcoholism or in your family?

If so, please elaborate.

Is there any history of illegal drug use in your family?

If so, please elaborate.

Has anyone in your family ever been diagnosed with a mental illness?

If the answer is "yes", please explain.

Has anyone in your family committed suicide?

If the answer is "yes", please explain.

Include a photo with your application (REQUIRED):

When we receive your completed questionnaire, we will review it and contact you. If you qualify to be a donor, we will send you a personality questionnaire. After receiving the completed personality questionnaire, we will contact you to set up a meeting.

Thank you very much for your time and your interest in becoming a donor and helping a couple to realize their dream of having a baby.

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