REPRODUCTIVE TISSUE BANK SERVICES

FERTILITY CENTER A NONYMOUS D ONO R S PERM

OF CALIFORNIA ANDROLOGY LABORATORY
S PERM C RYO B ANKING
E MBRYO S TORAGE

DONO R PROFIL E – DONO R CO DE 19PW

DEMOGRAPHIC AND PHYSICAL DATA
Date of birth (MM/YYYY) : 11/1984 Place of Birth (city/state) : SANTA CLARA, CA
Hair Color: DIRTY BLONDE Hair Type: WAVY Eye Color: BLUE
Race: CAUCASIAN Religion: AGNOSTIC Body Frame: ATHLETIC
Ethnic Origin (maternal) : IRISH/ GERMAN Ethnic Origin (paternal) : IRISH/ ITALIAN
Height: 5’11” Weight (lbs) : 200 Complexion: FAIR Blood Type: O+
PERSONAL AND EDUCATIONAL DATA
Marital Status (S/M/D) : S No. of Children: 0 No. of Siblings: 2
Occupation: STUDENT Degree/Major: B.A. ANTHROPOLOGY AND RELIGIOUS STUDIES

Career Goals: CURRENTLY WOKING TOWARDS M.S. IN AN ALTERNATIVE MEDICINE SYSTEM

Hobbies/Interests: HISTORY, ARCHAEOLOGY, ART, MARTIAL ARTS, MASSAGE AND ALTERNATIVE MEDICINE.

Describes himself as: SMART, ATHLETIC, WELL GROOMED, WITTY AND CHARMING

PERSONAL FAMILY BACKGROUND

Age Height Weight Complexion Hair Eye Education/ Age Cause of Death
Color Color Occupation Deceased
54 5’5” 200 FAIR BLONDE HAZEL M.S. COMPUTER
Mother
SCIENCE

Father 54 6’1” 200 OLIVE BLOND BLUE HIGH SCHOOL

TEACHER
SIB#1 35 5’10” 160 FAIR BLOND BLUE B.A.
ACCOUNTANT
SIB#2 32 5’8” 185 FAIR BLOND BLUE HIGHSCHOOL
HOUSEWIFE
SIB#3

SIB#4

SIB#5

MGM 80 5’5” 185 FAIR BLONDE BROWN RETIRED BOOK

KEEPER
MGF 5’11” 170 OLIVE BLACK HAZEL DRIVER 50 RESPIRATORY FAILURE

PGM 77 5’11” 110 FAIR BLONDE BLUE RETIRED PHOTO

DEVELOPER
PGF 5’11” 160 OLIVE BROWN BROWN APARTMENT 50 HEART FAILURE
MANAGER
SIB=Sibling F=Female M=Male
MGM=Maternal Grandmother MGF=Maternal Grandfather PGM=Paternal Grandmother PGM=Paternal Grandfather

6699 A LVARADO R OAD , #2208, 845 W. L A V ETA A VE ., # 104,

S AN D IEGO , CA 92120 http://www.spermbankcalifornia.com O RANGE , CA 92868
T EL : 619.265.0102 F AX : 619.265.1429 T EL : (714) 744-2040 F AX : (714) 744-2042
 REPRODUCTIVE TISSUE BANK SERVICES
FERTILITY CENTER A NONYMOUS D ONO R S PERM
OF CALIFORNIA ANDROLOGY LABORATORY
S PERM C RYO B ANKING
E MBRYO S TORAGE

DONO R PROFIL E – DONO R CO DE 19PW

DONOR / FAMILY MEDICAL HISTORY
Medical History Donor Relatives
Circulatory (Blood/Heart) PGF-HEART DISEASE
Gastrointestinal IBS GREAT GRANDMOTHER-STOMACH CANCER
SISTER HAD PROBLEM WITH PROGESTERONE PRODUCTION, NOW HAS
Genital/Reproductive
4 CHILDREN
Integumentary (Skin) HIVES
SOME
Mental Health
DEPRESSION
Metabolic/Endocrine SISTER HAD SOME THYROID ISSUES
Musculo/Skeletal
MOTHER-SCLEROSIS
(Muscle/Bones/Joints)
Neurological MGM-FLUID ON THE BRAIN;GREAT AUNT HAD SOME SEIZURES
Respiratory (Lungs) MOTHER, MGF, UNCLES HAVE ASTHMA
Sight/Sound/Smell
Urinary
SOME
Allergies ANIMALS MOTHER AND MGF HAVE ALLERGIES
AND HAY
Birth Defects
Genetic Diseases
DX=Diagnosed

GENETIC TESTING – TO BE ENTERED BY FERTILITY CENTER OF CALIFORNIA STAFF ONLY

Sickle Cell Anemia: N/A Tay-Sachs Disease: NON-CARRIER
Cystic Fibrosis: TESTED FOR 32 MUTATIONS. NEGATIVE FOR ALL
Chromosome Analysis: NORMAL MALE 46 XY.
Thalassemia: CBC/DIFF WITHIN NORMAL LIMITS. MCV IS NORMAL.

ADDITIONAL INFORMATION (PLEASE CIRCLE CHOICES)

Special Skills, Talents, Abilities: AGILITY, STRENGTH, STRUCTURALLY SOUND, VERY RARELY SICK AS A CHILD, SMART,
FLEXIBLE AND HAVE STRONG HANDS.

Languages: ENGLISH AND SOME:SPANISH, GERMAN AND ARABIC

Favorite Movies: LAST SAMURAI, GLADIATOR, MEMOIRS OF A GEISHA AND THE DEPARTED

Favorite Music: EVERYTHING

Favorite Sports: BASEBALL, SURFING AND MARTIAL ARTS

6699 A LVARADO R OAD , #2208, 845 W. L A V ETA A VE ., # 104,

S AN D IEGO , CA 92120 http://www.spermbankcalifornia.com O RANGE , CA 92868
T EL : 619.265.0102 F AX : 619.265.1429 T EL : (714) 744-2040 F AX : (714) 744-2042