All information I have about RR352
Date information was given 11/02
Physical and personal characteristics
Born in- April 1981
Place of birth- Louisiana
Eye color- Blue
Hair color and type- Brown/Curly
Religion born into- Roman Catholic
Years of collage-4
Interests- weight lifting, racquetball,guitar
Test results
Blood type- A positive
Chlamydia- Negative
Chromosome Analysis- 46 XY, normal male karyotype.
Cystic fibrosis-37 Common Mutations-negative.
CMV, IgG-Negative
Syphilis, antibody- Non Reactive
HbsAg and HbcAb- Non Reactive
Hepatitis C Ab- Non Reactive
Group B Streptococcus- Negative
Height- 6’3”
Weight-165
Heritage- English, French
Complection- Fair
Right handed or left handed- Right handed
Married-No
Children-None (11-14 donor children)
Occupation- College student engineering
HIV ½ Ab and HIV 1Ag- Non Reactive
HTLV-1, 2 Ab- Non Reactive
Neisseria gonorrhoeae- Negative
SGPT- Normal
Sickle cell- Non applicable
Tay Sachs and Canavan- Non applicable
Thalassemia- Normal adult hemoglobin
Trichomoniasis and yeast- Negative
Donor and family health History
Medical problems
Donor
Relative
Heart
None
Mother and maternal Grandfather- high blood pressure
Blood
None
None
Respiratory
Mild asthma
Mother- mild asthma
Gastrointestinal
None
Father-ulcer Grandmother- Survived colon cancer.
Metabolic/Endocrine
None
Paternal grandfather- diabetes
Urinary
None
None
Genital/Reproductive System
None
None
Neurological
None
None
Mental health
None
None
Muscles/Bones/joints
None
Maternal uncle-Muscular dystrophy
sight/sound/smell
None
None
skin
Mild acne (non-scarring)
Mother mild acne (non-scarring)
Other
None
None
Family History
Level of schooling: Mother: High School Father: High school
Occupation: Mother: Homemaker Father: Foreman/Industry
Age if living
Age at time of death
Cause of death
Mother
44
Father
50
Maternal Grandfather
64
Gunshot victim
Maternal Grandmother
65
Paternal Grandfather
75
Paternal Grandmother
50
Blood clot
Brothers
None
Sisters
15
Donor motivation
The following questions are being asked to determine your attitude about being a donor. Currently, this donor program, like others in the united States, uses only anonymous donors.
Why do you want to be a donor? Assist anonymous couples and financial reward.
Have you been a donor at another semen bank or physicians office? No If yes where? For how long? Were there any births?
Would you continue participation without reimbursement for the time and expenses associated with the donation of your semen specimen? No
Would you continue to participate without anonymity? No
Would you agree to meet with the recipient couple? No
Would you agree to meet with donor offspring at age of 18? No
* present legal statutes and standards prohibit donor / recipient disclosures
7. How do you feel about descriptive, but non-identifying information about you being given to the recipient family?
I suppose they deserve to know what they’re getting.
Personal health history
Place of birth: Louisiana Race: white, non-hispanic
Ethnic ancestry: Mother: English Father: French, English
Are you adopted? No Eye color: Blue Complexion: Very fair Weight: 165 lbs. Height: 6’3”
Bone size: Small-Medium Hair color: Brown Hair texture: Wavy
Hair condition: Donor: Average Father: Average Male siblings:
Freckles: some Dimples: No Cleft chin: No
Other:
Predominant hand: Right Domestic status: Single Has a woman ever become pregnant by you? No
Number of own children fathered: none
Number of Male blood siblings (brothers): None Number of female blood siblings (sisters): One
Have twins or multiple births occurred in your family? No
What religion were you born into? Catholic
What is your current religious preference? N/A
Have you had more than one sexual partner within the last 6 months? No
Do you have any tattoos? No
Have you ever had acupuncture, ear piercings, or body piercings? No
Have you ever been convicted of a crime? No
Highest Degree Earned: High school Are you currently a student: Yes
What year are you in school? Senior
What is or what was your major area of study? Mechanical Engineer
Number of years completed after high school? Donor: 4 Mother: 0 Father: 0
Mothers highest degree: High school Mothers occupation: House morn
Father’s Highest degree: high school Father’s occupation: Mechanical Foreman
What is your current or most recent occupation/work? ( If you are a student, indicate any job you hold in addition to school) Sever
What are your future occupational goals? Mechanical Engineer
Subjects enjoyed enjoyed most: Natural Science,Languages, and Computers.
Subjects enjoyed least: Social studies.
Mathematical Skills: Above-average Explain: Most math comes easy to me
Mechanical skills: Above-average Explain: I like to know how things work so I can apply and build on that knowledge.
Athletic skills: Average Explain: Never particularly talented at any one sport, but can hold my own in most any club sport
Musical skills:(instrumental) Low Explain: Never interested until recently
Musical skills: (vocal) Average Explain: Spent six years in school choir, 2 of which were in “select” group
Language skills: (written) High Explain: My english teacher professor tried to change my major to english
Language skills:(verbal) Above-average Explain: I can write a killer speech, but get a little nervous on delivery
Artistic skills: (theater) Explain: Never really tried it
Artistic skills: (draw/paint) Below-average Explain: I pretty much use a straight edge for everything
Do you have any additional special talents, abilities, skills? Be specific and describe:
PREFERENCES
Pets: like outdoor pets Music: huge music fan
Team sport: loves hockey (spectator of course) Individual sports: likes racquetball as regularly as possible
School: no opinion depends on my mood
What is your favorite color: purple What is your favorite foods? Pastas Mexican
Where would you like to travel? Pairs, New York, Seattle, Chicago, San Francisco, Boston, And D.C. Never been
What are your current hobbies or interests? Weight lifting, racquetball, trying to learn guitar.
How do you get along with people( patents, friends, boss, etc): Very well I’m a fairly easy going person, I like to socialize.
How do you solve your personal problems and make decisions ( quickly, after carefully exploring all points of view, with dehberation, etc): I try to weigh pros and cons and base my decision on that.
What are your Goals/Ambitions/Future plains/ Feelings? Underline all that apply.
Help people Immediate family
Good job Social Acceptance
Marriage/Family/Kids Public service
Improve Environment Politics
Decent wage level Financial Security
Travel Success
God Religion To be Happy
Become Financially independent Initiate Own Business/Be Own boss
How would you describe your personality traits? Underline all that apply.
Extrovert Quiet Enthusiastic Intelligent
Introvert Loud Energetic Well-adjusted
Passive Thoughtful Adventurous Caring
Submissive Humorous Concerned Pessimistic
Easy-going Creative Kind Intense
Outgoing Friendly Happy Egotistic
Moody Perfectionist Temperamental
Personal health History
Do you have allergies? Yes If yes what are they to: Environment
List specific substances and reaction produced: Pollen and dander- sinus problems
Describe any childhood allergies you have outgrown: Peanuts
How is your vision (without glasses)? Good (With glasses)? Excellent Do you wear glasses or contacts? Yes
Do you have normal hearing? Yes
Condition of your teeth (choses one) Poor Fair Good X
Your diet: Vegetarian-Excellent diet
How much exercise do you get? Regular
What type of exercise? Weights and Aerobic
Have you ever had any serious illness or surgical procedures in the past? No
Have you ever had any major illness such as amoebic dysentery, hepatitis, pneumonia, mononucleosis,ect? No
If yes please explain.
Have you ever received transplants of human durs matter? No
Have you ever been seen by a physician or been hospitalized in the past two years? Yes- Viral infection ( 24 hour flu)
Have you ever taken antimalarial drugs or had malaria? No
Have you had any hospitalization not already mentioned?
Have you ever been treated for syphilis? No
Have you or any of your sexual partners ever had:
NSU Non Specific urethritis Yes No X
Chlamydia Yes X No
Venereal warts Yes No X
Herpes Yes No X
Other sexually transmissible diseases Yes No X
In the last six months have you had a sexual partner who has had a Trichomonas infection? No
In the last 12 months have you had sex or close contact with anyone who has had?
Genital Herpes No
Genital Warts No
Chronic Hepatitis (carrier) No
Have you exhibited any of the following conditions within the last 12 months?
Dysuria (painful urination) No
Urethral Discharge No
Genital Ulcer No
Please list any medications you are currently taking or have taken on a regular basis: Allegra-D and Accolate
Have you been vaccinated for any reason in the last 12 months? No If yes why and when?
Do you drink alcoholic beverages? Yes If yes what kinds? Beer and liquor
Approximately how many drinks per day or per week do you consume? 4/week
If you drink less than 3 drinks per day, was there ever a time when you drank more? No
Do you use tobacco products? No If yes what kind?
If cigarettes how many packs a day? How long have you been smoking regularly?
Have you ever used or do you use any of the following drugs?
Drug Yes No Frequency/ year(s) How Used
Marijuana No
Cocaine No
Barbiturates No
Narcotics/Opiates ( heroin, opium
methadone, morphine, codeine) No
Amphetamines No
Hallucinogens No
Tranquilizers No
PCP No
Inhalants No
Steroids No
Over the counter drugs? Yes- use as directed
Have you ever traveled outside the United States (except Canada) in the past three years? No
If yes when? Where?
Have you ever been exposed to “ agent orange” or any other herbicides or chemicals in Vietnam or elsewhere (forest service, Highway maintenance, ect.) No
What is your current most recent occupation? Server
Please list all the jobs you have ever had in the past 5 years and your possible exposure to chemicals, drugs and gases. Please consider carefully.
Jobs/Duties
Dates of employment
Year began Year ended
Exposed to which drugs, chemicals, gases
Server
2001
Present
None
Police Aid
1999
2002
None
Gym Attendant
2001
2002
None
Pawn Broker
1997
2000
None
In the past six months have you been to any EXCESSIVE amounts of the following in your living environment or while involved in hobbies “ If yes to any of these check the appropriate item below and give dates and how often you have been exposed.
Toxic chemicals or substances Yes No X
Radiation Yes No X
Flea powder/sprays Yes No X
Lead Products Yes No X
Cleaning solutions/solvents Yes No X
Genetic history
Please describe your family members by the following:
Eye color
Hair color
complexion
Height
Body type
Ethnic origin
Mother
brown
fair
5’8”
Medium-large
English
Father
brown
medium
5’10”
Medium-large
English-French
Maternal
Grandfather
Maternal
grandmother
Paternal
Grandfather
Paternal
grandmother
Has any member of your family including yourself had a problem of defect at birth of any of the following body
Bones, muscles,joints,limbs: No
Gastrointestinals system: No
Nervous system, brain, Spinal cord: No
Blood circulation: No
Respiratory system: Yes
Organ (heart, lung, kidney, ect): No
Genitaln/Urinary: No
Metabolic (hormones, enzymes, ect.): No
If yes list the specific defect in each case: My sister had respiratory problems.
Do you have any brothers or sisters who died in infancy or childhood? Yes
Are there any known genetic diseases or conditions that run in your family? Yes- High Blood pressure.
Do you have a family history of any of the following medical conditions?
Tay-sacks: No
B-thalassemia: No
Dementia or degenerative neurological disorder No
If yes please explain in each case:
Has anyone in your family including yourself experienced recurring and or chronic physical symptoms that has been evaluated by a physician? (Please include those symptoms that you may not consider serious) No
Check through the following list of medical problems and indicate which ones you or one of your relatives has had. Please consider each condition carefully for each family member.
Medical problem
none
You
Mother
Father
Sibling
Child
Grand-
parent
Aunt-
uncle
cousin
Heart
stroke
X
Heart attack
X
Heart disease
X
From birth
X
Other
X
High blood pressure
X
Blood
Anemia
X
Sickle-cell anemia
X
Hemophilia or other bleeding problems
X
leukemia
X
Immune deficiency
X
Other blood disorder
X
Respiratory lung
Hay fever
X
Asthma
X
X
Emphysema
X
Tuberculosis
X
Lung cancer
X
Pneumonia
X
*other lung diseases
X
Gastrointestinal
Stomach/ duodenum ulcer
X
Gallstones
X
Hepatitis A (infectious)
X
Hepatitis B (serum)
X
*other liver diseases
X
Colon Cancer
X
Ulcerative colitis
X
Crohn’s disease
X
Cystic Fibrosis
X
Intestinal cancer
X
Other cancer problems of digestive system
X
Metabolic/ Endocrine
Diabetes mellitus
X
Hypoglycemia
X
Thyroid cancer
X
Thyroid disease
X
Goiter
X
Adrenal dysfunction/ disorder
X
Hyperactivity
X
Urinary
Kidney disease
X
Other disease of urinary tract (urethra, bladder, ureter)
X
Renal disorder
X
Genital/ Reproductive system
X
Undescended testicel
X
Hypospadias
X
Prostate cancer
X
Uterine fibroids
X
Ovarian cysts
X
Other of cervix, ovaries or uterus
X
Neurological
Migraines
X
Mental retardation
X
Senitility before age 50
X
Multiple sclerosis
X
Cerebral palsy
X
Epilepsy/ seizures
X
Hydrocephalus (water on the brain)
X
Disorders of the spinal cord
X
Huntington’s chorea
X
Gaucher’s disease
X
Wilson’s disease
X
Creutzfeldt- jacob disease
X
Degenerative disorders
X
Alzheimer’s
X
Brain tumor
X
Other diseases of nervous system
X
Mental Health
Schizophrenia
X
Manic depressive
X
Muscles/ Bones/ Joints
Muscular dystrophy
X
Other chronic muscle diseases
X
Lupus
X
Deformity spine
X
Osteoporosis
X
Dwarfism
X
Heredity low back disorder
X
Arthritis
X
Gout
X
Club foot
X
Sight/ Sound/ Smell
Deafness before age 60
X
Deformity of the ear
X
Cataracts before age 60
X
Blindness
X
Color blindness
X
Glaucoma
X
Deviated septum
X
Other sight/ smell/ sound disorder
X
Skin
Acne
X
X
Eczema
X
Skin cancer
X
Pigmentation disorders
X
Infectious skin disease
X
Other skin disorder
X
Other
Alcoholism
X
Drug abuse, misuse or addition
X
Breast cancer
Xw
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