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 06SQ

DEMOGRAPHIC AND PHYSICAL DATA
Date of birth (MM/YYYY) : 02/1984 Place of Birth (city/state) : FAIRFAX, VA
Hair Color: BROWN Hair Type: THIN Eye Color: HAZEL
Race: CAUCASIAN Religion: CHRISTIAN Body Frame: ATHLETIC
Ethnic Origin (maternal) : POLISH Ethnic Origin (paternal) : GERMAN
Height: 6’3” Weight (lbs) : 205 Complexion: FAIR Blood Type: O+
PERSONAL AND EDUCATIONAL DATA
Marital Status (S/M/D) : S No. of Children: 0 No. of Siblings: 0
Occupation: LAW STUDENT Degree/Major: PSYCHOLOGY

Career Goals: PRACTICE LAW IN SAN DIEGO

Hobbies/Interests: BASKETBALL, FILM MAKING

Describes himself as: OUTGOING, KIND AND FUNNY

PERSONAL FAMILY BACKGROUND

Age Height Weight Complexion Hair Eye Education/ Age Cause of Death
Color Color Occupation Deceased
Mother 60 5’8” 140 FAIR BROWN BROWN CAREER
COUNSELOR
Father 62 6’3” 200 FAIR BROWN BLUE ENGINEER

SIB#1

SIB#2

SIB#3

SIB#4

SIB#5

MGM 85 5’4” 180 FAIR BROWN BROWN ADMINISTRATIVE

SECRETARY
MGF 5’11” 180 FAIR BROWN BLUE ELECTRONICS 71 LIVER CANCER
TECHNICIAN
PGM 5’8” 150 FAIR BROWN BLUE NURSE 72 BONE CANCER

PGF 6’0” 180 FAIR BROWN BROWN ACCOUNTANT 50 BRAIN CANCER

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 06SQ

DONOR / FAMILY MEDICAL HISTORY
Medical History Donor Relatives
Circulatory (Blood/Heart)
Gastrointestinal
Genital/Reproductive
Integumentary (Skin)
Mental Health COUSIN WITH SCHIZOPHRENIA
Metabolic/Endocrine
Musculo/Skeletal
(Muscle/Bones/Joints)
Neurological
Respiratory (Lungs)
Sight/Sound/Smell
Urinary
Allergies √
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: SPEAK SPANISH, GOOD PUBLIC SPEAKER

Languages: ENGLISH AND SPANISH

Favorite Movies: USUAL SUSPECTS, SHAWSHANK REDEMPTION

Favorite Music: RAP

Favorite Sport: BASKETBALL

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