Egg Donor Profiles

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EDC0160617

PROFILE

GENERAL DETAILS

  1. Age:   25                                              Year of Birth: 1992
  2. Husband’s Age: 27
  3. Native: Mettupalayam
  4. Height: 4.7 Ft
  5. Weight: 43
  6. Education: Polytechnic discontinued       From 2007Year to 2008Year
  7. Religion:Hindu
  8. Veg/Non-Veg:Both  
  9. Nationality: Indian

10. Identity Proof: Voter

11. Blood Group: B Positive

12. Languages known: Tamil, Telugu & Malayalam

 

PHYSICAL APPEARANCE

  1. Physical Build                              Small       

2.               Skin Complexion                         Fair                     

 

3.               Eye Color:                         Light Brown

4.               Hair Color:                        Back

5.               Natural Texture of Hair:               Thin                   

                   

MARITAL STATUS

Married     

MARRIED

  1. Date of Marriage: 22.05.2013                
  2. Has your husband accompanied you for the interview? Yes         

If not, reason for the same:

 

3.               Have you been married more than once?                   No

4.               Does your husband agree?                              Yes

5.               Do you have a marriage certificate or any proof of marriage?

          No

If yes, Proof Type                        ID Number

 

PERSONAL CHARACTER

  1. Please describe your personality and character?

Caring and hardworker

2.               What do you like most about yourself?

Sincerity in my work

3.               What are your hobbies and interest?

Hearing songs

4.               What is the work that you would love to do most?

cooking

5.               How do you emotionally feel about being an egg donor?

Feel happy

6.               What was your most interesting subject in your education?

Social Science

7.               How attached are your towards your family?

Mostly attached with husband and spend time with family

 

HABITS

  1. Do you use tobacco or do you smoke?             No
  2. Do you consume alcohol?                                No
  3. Does your husband use tobacco?                     Yes Occasionally
  4. Does your husband consume alcohol?             Yes Occasionally

 

PREGNANCIES

  1. Have you ever had a fertility problem?              No

If YES, please give details

 

2.               Have you had a multiple birth?                         No

3.               How many children do you have?

Male

1

Female

 

         

4.               Have you ever suffered a miscarriage?             No

5.               Have you undergone MTP?                             Yes 4 years before

6.               Have you ever any ectopic pregnancies?          No

7.               Have you suffered a stillbirth?                          No

8.               Have you suffered from Post-natal Depression? No

If yes, please provide details of the same.

         

9.               Have you undergone surrogacy earlier?            No

10.           Have you taken up egg donation earlier?          No

If yes, please provide details of the same.

 

 

11.           Please give details of deliveries:

 

1

2

3

4

Normal/

C-Section

Normal

 

 

 

Dates of Birth

15.09.2013

 

 

 

Weight

3kg

 

 

 

Was pregnancies full term?

Yes

 

 

 

Did any of your children have a medical problem at birth

No

 

 

 

Do any of your children have health problems? (Physical or Psychological)

No

 

 

 

 

FAMILY PLANNING

  1. Have you done family planning?                       No 
  2. Present contraception method?                        No

Describe –

3.               Has your husband done family planning?          No

4.               If answer to the above two questions is No, do you understand the importance of abstaining from Intercourse at the time of ovulation?

Yes          

5.               Have you completed your family?                     Yes

 

MEDICAL

  1. Have you gained or lost over 10 kilos in the past six months?

No

If yes, please give details

2.               Have you been immunized?                             Yes

3.               Have you ever had any psychiatric problems?   No

4.               Are you presently taking any medication?         No

5.               Do you have any diseases, such as, diabetes/epilepsy, etc.

No

6.               Are you known allergic to any particular drug or substance/food?

No            If yes, specify

7.               How long is an average monthly cycle for you?                     28      days

8.               How long do your periods last?                                  3        Days

9.               LMP: 22.05.2017

10.           Do you wear glasses?                 No

If yes, what is the type and power?

 

FAMILY MEDICAL HISTORY:

  1. Does anyone in your family have any genetic diseases, such as, diabetes, epilepsy or any heart problem?              No
  2. Does anyone in your family have twin children?          No
  3. Is there some medical condition in your family that you might consider would pass on genetically?                                        No

 

MEDICAL (PARTNER):

1.     Is your husband suffering from disease that is transmittable orally, such as, TB, etc.                                                                      No

2.     Is your husband suffering from any Sexually Transmittable Disease?

          No

3.               Is your husband suffering from any psychiatric problem or any mental issue?                                                                       No

 

SUPPORT

  1. Do you have someone to offer practical and emotional support?

     No

Name and relation:

2.               Is your family aware of your intention to become a surrogate mother/egg donor?

No

 

CONVENIENCE

  1. If chosen, how far are you prepared to travel to a clinic?                  Within Coimbatore
  2. Are you willing to travel to any other city other than your present residence?              No

 

EMPLOYMENT:

  1. Are you currently employed?                            Yes                    
  2. Occupation/Nature of work:                    Samsung Promotor
  3. Previous occupation:                            
  4. If YES, how many hours a day/week?               8 hours
  5. Would your employer allow you time off to attend hospital/clinic appointments for treatment etc.?                      Yes
  6. If you are employed or have been employed, what is the pay that you had been receiving? Rs.20,000/-
  7. Is your spouse currently employed?                  Yes
  8. Nature of work/occupation of your spouse: Driver

Family details

Please write a short statement about you, your family, and most importantly your reasons for wanting to be a surrogate mother/egg-donor. Please also mention other information you wish to communicate to the intended parents.

To take care of the child in a good manner

 

LEGAL COUNSELLING

Are you being forced into taking up the egg donation/surrogacy arrangement by anyone?       No

Are you willing to be a surrogate mother/egg donor only out of your Free Will?

Yes          

Do you or your spouse have any criminal convictions, or criminal proceedings pending?                           No

 

EGG DONOR

1.     Do you know that you have to complete your family before you can get enrolled with Givlifes Egg Donor Program?

Yes

2.               Do you know that you have a risk of becoming infertile, if selected?

Yes          

3.               Are you informed of the following:

a.               The basic process of Egg Donation        Yes          

b.               The gametes (eggs) that would be retrieved from you by ART by stimulation with hormonal drugs would be the sole property of the childless couple.                                                           Yes          

c.               You would have no control over the gametes that have been retrieved from you or the child that may be created/born out of such gametes?

Yes          

d.     You still remain an anonymous Egg Donor, shall have no knowledge of who would be using your gametes?          Yes          

e.               You would not be making any attempt to identify the childless couple whom you are helping.                                     Yes

4.               Do you have any doubts/queries?

No

 

 

COMPENSATION:

  1. What is your monthly income? Rs.20,000/-
  2. What is the monthly income of your family? Rs.40,000/-
  3. Do you or anyone in your family own any movable or immovable assets? Yes
  4. If you were selected, how much compensation according to you would be appropriate for your services?

Rs.35,000/- to Rs.50,000/-

5.               What would you do with the compensation that would get out of this effort?

To spend towards child’s education

6.               Something that you would like to communicate to childlesscouple that you would help in the process?

Will co operate my best