Protected: Malu
Location:
Age: 22 years old
Blood group: B
Height: 170
Weight (lbs): 48 kg
Hair Color: Light brown
Eye Color: Hazel
Highest Level of education: Bachelor Degree
College Major: Tourism
What was your college GPA? A+
Ethnicity: Indian
Business Administration Technological College Do you have any artistic abilities? Please List: Singing and Trombone
Do you have any athletic abilities? Please list: Swimming
Occupation? Model/student
Do you wear or have you worn eyeglasses? If yes, at what age did you start wearing them? No
Have you worn braces? No
Why do you want to become a donor? To help women become mothers.
Do you feel prepared to commit to this process? Yes
Are you open to being matched with all types of families regardless of sexual preference, marital status, ethnicity or sex of the egg recipient? If no, please explain.Yes
If they request it, are you willing to meet your intended parents? Yes
Are you open to meeting the child in the future if that is requested? Yes
Are you open to exchanging future contact information with your intended Parents(s)? No
Do you have any siblings? If so, tell us about each of them: No
Do you have any children? If so, tell us about each of them: No
Personal Health History
Any past or current medical problems (including surgeries, accidents, birth defects, depression, etc.)? If yes, please list: No
Do you drink alcohol? If yes, how many drinks per week? No
Have you ever been pregnant? If yes, how many times and what was the out-come? I have never been pregnant.
Have you ever been a donor before? If yes, did a pregnancy occur? Yes
Are you currently taking any medication (for physical or mental health)? If yes, what medications are you on and why? No
Are you taking any recreational drugs? If yes, what are you taking? No
Do you smoke? No
Are your menstrual cycles regular? If no, please explain: Yes
Family Medical History
Note: Medical history will be verified. Anything purposefully omitted may result in being dropped from the program. If any of the following has occurred in your family, please list which family member and explain:
Family Genetic History
Biological Family Member Sex Age Height Eye Color Hair Color Education Level Deceased Occupation
Father M 80 190 Blue Light brown Bachelor’s degree retired
Mother F 55 160 Light brown Light brown collage House wife
Paternal Grandmother F blue Light brown Bachelor’s degree ⁄
Paternal Grandfather M blue Light brown Bachelor’s degree ⁄
Maternal Grandmother F 72 160 Light brown Light brown collage Business owner
Maternal Grandfather M 75 185 Light brown Light brown collage Business owner
Disease/Medical Condition Check one To Whom Passed away? Age of onset/Medication Age at the time of passing
Cancer No No
Mental Retardation No No
Autism / Asperger’s No No
Physical Malformation No No
Paralysis or crippling disorders No No
Alcohol or Drug Addiction No No
Cystic Fibrosis No No
Sickle Cell Anemia No No
Lupus No No
Miscarriages, still births, neonatal
deaths□ No No
High blood pressure, heart attacks
or strokes□ No No
Memory loss or dementia No No
Osteoporosis No No
Arthritis No No
Allergies No No
Blood diseases No No
Diabetes (Specifically Type 1 or Type 2)□ No No
Thyroid issues No No
Learning disabilities No No
Seizure or epilepsy No No
Disease/Medical Condition Check one Passed away? Age of onset/Medication Age at the time of passing
Depression No No
Panic attacks No No
Schizophrenia No No
Bipolar Disorder No No
ADD or ADHD No No
Age-related issues No No
Kidney problems / diseases No No
Reproductive problems: i.e. endometriosis, hysterectomies, lateterm miscarriages, etc. No No
Vision/Sight/Eye Problems No No