Donor & Family Health History

Medical ProblemDonorFamily
HeartNone

None

Blood
NoneNone
RespiratoryNone
Grandfather:  Hayfever
Gastrointestinal
NoneNone
Metabolic/Endocrine
NoneNone
UrinaryNoneNone
Genital / ReproductiveNoneNone
NeurologicalNoneNone
Mental HealthNoneNone
Muscles / Bones / JointsNoneNone
Sight / Sound / SmellNone
None
Skin
None
None
OtherNonePaternal Grandfather:  Alcoholism


Test Results
Test Results
Blood TypeO+
HIV 1/2 Ab; HIV 1 Ag
Nonreactive/Nonreactive
ChlamydiaNegative
HTLV-1,2 Ab
Nonreactive
Chromosome AnalysisNormal Male 46XY
Neisseria gonorrhea
Negative
CMV ScreenPositive
SGPT
Within normal limits
CMV, IgM/Culture
Not applicable
Sickle cell
Not applicable
Cystic FibrosisNegative for 37 Common Mutations
Syphilis, antibody  MHA-TP
Nonreactive
HbsAg
Nonreactive
Tay Sachs & Canavan
Not applicable
HbcAb
Nonreactive
Hepatitis C, Ab
Nonreactive
Thalassemia
Normal adult hemoglobin
HCVRNA/HIV-1 RNA
Nonreactive/Nonreactive
Notes


Identification #RR351


Pregnancy Proven - Yes
Physical & Personal Characteristics


Date of Birth (Y)1983
Place of BirthMississippi
Height5'10"
Weight180
Eye Color
Blue
ComplexionFair
Hair
Light Brown, Curly
Right Handed     X
Left Handed        
Religion Born IntoRoman Catholic
Married   No
Heritage
German

Occupation  College Student; majors Computer Systems and Spanish

Years of College  2
Interests  Running, Weight lifting



Notes  Standard (ICI) and Prewashed vials (IUI) vials available 



Family History


Family MemberOccupation
Level of Schooling
Mother
Nurse/Drug Rep

B.S.
FatherBusiness Owner

B.S.




Family MemberAge if LivingAge at DeathCause of Death
Mother48


Father52


Maternal Grandmother68


Maternal Grandfather67


Paternal Grandmother68


Paternal Grandfather
50
Cirrhosis of liver due to alcoholism
Sisters


Brothers22