Birth Mother Donor Risk Assessment Interview

DR-003, Rev.03

This interview will provide additional information about your medical and social history that may help us determine the best use of the gifts for which you have consented. Many of the questions are personal in nature. Please answer all questions honestly to ensure the safety of patients who receive your donation. All information you provide is confidential.

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DEFINITIONS

For the next part, sexual activity and sex refer to any method of sexual contact including vaginal, anal, and oral

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Have you EVER had a positive or reactive test for:

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