Oregon Health & Science University                 PROFILE FOR SPERM DONOR     #6561
Andrology/Embryology Lab

3303 SW Bond Ave., CH10F

Portland, OR   97239-4501

(503) 418-3700

 

PHYSICAL CHARACTERISTICS

 

FAMILY AND MEDICAL HISTORY

For each item below, if there is a history of the condition, the condition poses a risk of one percent or less to offspring. The family relationship is indicated.

 

ABBREVIATIONS:                                      M=Mother, or Maternal      S=Sibling                      F,P=Father, or Paternal

N=Nephew or Niece                                              GF, GM=Grandfather, Grandmother

A=Aunt                             U=Uncle                        C=Cousin

 

MEDICAL HISTORY COMMENTS:  Living are the donor’s father (age 74), mother (65), MGM (90), 1 P aunt (54), 1 P uncle (68), and 1 sister (26).  Deceased are the PGF (at age 78 of pulmonary embolism and pneumonia), PGM (at 63, renal dysfunction of unknown etiology), MGF (93, congestive heart failure, healthy until age 90), and M uncle (42, sudden brain aneurysm, possibly stress-related from job).  Donor’s father was diagnosed with atherosclerosis at age 63 (was daily smoker for 25 years and ate high fat/cholesterol diet) and has had single bypass surgery for a partially blocked artery, and the varicose veins in his legs were medically removed; also, donor’s father lost some hearing during childhood after a high fever, most likely scarlet fever.  Donor’s mother was diagnosed with osteoporosis at age 63.  MGM’s hypertension was diagnosed at age 80.  The P uncle is a lifelong smoker.

Donor’s vision: 20/15 in both eyes (20/200 prior to Lasik surgery)

Donor’s hearing: excellent.

Donor’s dental history: two fillings, wisdom teeth extraction.

 

OCCUPATION:      Post baccalaureate student

RELIGION:      Agnostic/Atheist

 

Sperm Donor Social History:

1. Do you have any special talents? If so, please list them.

Learn foreign languages quickly, very good with language/verbal tasks in general (97^th percentile on verbal portion of GMAT and 95% percentile on verbal portion of GRE)

 

2.Are there any special talents that seem to run in your family?

(athletics, music, artistic, etc.). Please list, including family members.

Music (mother played instrument, sister and I both played instruments and were in a youth orchestra in high school), mother and sister talented at painting and sketching.

 

3. What are your interests and hobbies? If appropriate, please include when and at what level you do or did participate in this interest or hobby.  Please elaborate.

Scuba diving (licensed)

Travel

Writing (screenplay and fiction writing)

Filmmaking

 

4. What did you enjoy studying in high school and college?

Astronomy, literature, history

5. GPA, High School:   3.9    GPA, College:  3.5              I.Q.:  130   

 

6. How would you describe your personality characteristics?

(e.g. funny, quiet, shy, bold, leader, thoughtful, etc.) List as many as you can.

Innovative, creative, adventurous, curious, open-minded

7. Why do you want to be a sperm donor?

Supplement income, pass genes on to the next generation, help women and couples who can’t or don’t want children through other means.

Additional Descriptive Characteristics:

 

Handedness:     Right

 

Foot/Shoe Size:      10 

 

Hairy Chest:         NO

 

Hairy:                     NO

 

Beard Color:     black

 

Any Distinguishing Features (Dimples, Cleft Chin, Roman Nose, Freckles, etc.):     no

Acne problems:     no

Reactivity/Sensitivity to sun exposure:         no, do not burn easily

Donor Family Social History:    

                               

	Education	Occupation	Interests	Eye color	Hair color	Height	Body Type
PGF	high school	Army officer		Black	brown	5 ft 5”	slim
PGM	high school	Housewife		Black	Black	5 ft	slim
MGF	high school	Entrepreneur	Gardening, nature	Black	Black	5 ft 5”	slim
MGM	high school	Housewife	travel	Black	Black	5 ft	slim
Father	MA (history)	Tool and dye maker	History, politics, reading	Brown	Brown	6’ 3”	Slim
Mother	MA (education)	Teacher (high school)	Gardening, cooking	Black	Black	5’	Slim
Sister	Master’s degree	Teacher	Travel, cinema, music	Black	Black	5’3”	Slim
Cousin	College	Banker	Travel, outdoor/water sports	Black	Black	5’3”	slim
Uncle	College	Don’t know	Don’t know	Brown	Brown	6’4”	slim
Uncle	College	Don’t know	Don’t know	Brown	Brown	6’4”	slim

 

 

Psychological Assessment and Comments from Paula Acker LCSW, an independent Psycho Social Counselor, following an Interview with donor 6561:

 

Referral Information:  Donor 6561 was referred by Oregon Health and Sciences University Fertility Consultants for a psych-social evaluation to be an anonymous sperm donor for OHSU.  Prior to this evaluation he has had a medical evaluation with OHSU. This in depth evaluation followed the guidelines of the American Society of Reproductive Medicine Mental Health Professional Group recommendations for anonymous donors and includes the PAI psychological testing with results to follow in this report.

 

Motivation for Donation:  Donor is a single male of Japanese and German heritage that has volunteered to be a donor because he feels good about passing on his genes to the world gene pool. He understands that there are a lot of people unable to conceive without anonymous donors and he wants to help them. He has a very positive attitude about being a donor and feels this is an important way he can make a contribution to society. He is also motivated by the compensation that donors receive. He is more than open to being an Information Release Donor and wanted to be sure that I mentioned this in the report.

 

Informal Mental Status and Behavioral Observations:  Donor was on time to this appointment and appropriately dressed. He has a very upbeat and positive personality style and was oriented to person, place and time and did not display any cognitive deficits. His mannerisms and language skills were above average and he answered all questions in an intelligent and thoughtful manner. He has a kind disposition and a genuinely warm smile. 

                                                                                       

Brief Psychosocial History:  Donor grew up in Oregon and works full time in a medical research position. He did his undergraduate work at a small private college  earning a BA in International Studies and also has a Masters Degree in Education. He taught school in Japan for a couple of years before returning to Oregon. His parents divorced when he was thirteen. Neither parent is remarried. His mother works full time in a high school teaching. His father is a retired tool and dye maker. Both parents are in good health. He has one sibling, a sister. She just graduated with a Masters in Education but is interested in becoming an actress. She is healthy.  Donor states he is also very healthy.

 

Psychological Family History:  Donor states there is no history of mental illness in the family of origin and no history of alcoholism.  He is a light social drinker averaging about two beers a week with his friends. He has never sought professional counseling or had depression. He is a non-smoker and does not use recreational drugs, although he did smoke marijuana up to about one and half years ago, when he quit.  He has no legal or financial problems or any bankruptcies.  He is self supporting and currently resides at home with his mother to save money.  He states to have never had substance abuse problems. He has no history of physical, sexual or psychological abuse.

 

Hobbies and Interests:  His passion in life is travel and he is pursuing travel whenever he has the opportunity. He has traveled to many countries around the world and wants to continue traveling.  He also enjoys scuba diving, basketball, and is training for a triathlon.   In addition he enjoys writing and writes fiction and screen plays.

 

Psychological Testing Results: Donor took the PAI psychological test and all of his scores were in the normal limits.  There is no indication of any psychopathology based on this test and he reported no problems with antisocial behaviors, hostility, moodiness, or depression.  He reported no problems with alcohol or drug dependency.  His self concept is a stable and positive personality that is confident and optimistic with a clear sense of purpose.  He is self satisfied with his goals and has a good support network of friends and family.

 

Recommendation:  Donor meets the ASRM Mental Health Professional Group recommendations for anonymous donors and along with the clinical interview and testing results is recommended as a donor for Oregon Health and Sciences University Fertility Consultants.  It was a delight to meet this donor as he is a caring and intelligent young man with a positive attitude about life and has an engaging personality.

 

 

 

CHILDHOOD PAGE

 

1. In general, please describe your childhood.  Did your family stay in one place, or did you move often? What is your recollection of these places/homes? If you have siblings, how did you get along with them?

Family moved several times (from WA to NH when I was one, NH to OR when I was seven).  I had a very happy childhood growing up in the countryside on a farm, surrounded by nature and always playing outdoors.  We moved to the suburbs when I started middle school.  I have one sister and we’ve been very close our entire lives.  We’re two years apart so we played together all the time.

 

2. Were there any family members other than your parents and siblings with whom you regularly had contact? Please relate a story(or stories) or an incidence(or incidences) that you particularly remember of him/her/them.

All of my extended family lives in Canada, Japan and Germany so I rarely saw them growing up.  My cousins from Japan visited every five years or so.

 

3. As a child, what was your favorite:     (Please include a reason, or why, if you can.)

   

Food(s): sushi, pizza, Japanese food (tempera, miso soup, etc.).  I liked sushi and Japanese food because we ate it often (my mother is Japanese).  I think everyone likes pizza.

   

Colors(s): red (because it was flashy and exciting), blue (soothing, the color of water, which I loved playing in)    

   

Toy(s): Lego blocks and stuffed animals.  I loved building things and acting out plays with my stuffed animals.                    

   

Indoor Game(s):  Board games, drawing, playing with other toys (was not allowed to have video game system until I was 16, so rarely played video games before then)    

   

Outdoor Game(s): Tag, basketball, four-square, two-square, wall-ball, touch football

   

Book(s): The Chronicles of Narnia, The Hobbit, Harriet the Spy, Greek myths

 

Sports(s): basketball, touch football

 

Other Activity(s): mountain biking, exploring and hiking, camping
                                                        

4. What is your earliest memory?

Tasting maple syrup freshly tapped in buckets during winter in New England.  My father reading children’s books to me.  Exploring outside my house in New Hampshire.

 

5. What did you do during the summers?

Swimming, played video games and played outdoors with friends (basketball, tag, white-water rafting).  Watched movies at night.

 

6. Are there any new technologies you remember becoming available during your childhood which now are commonplace in our society, or which have now been replaced by a newer technology? Explain your recollection of these.

Atari video game console (Frogger, Pac-man) and the NES.  Now we have sophisticated consoles like the Xbox 360.  I also remember the Apple II, which I used in elementary school and the rise of the internet.

 

7. Did you enjoy school as a child? Do you have any memories of teachers that influenced you, or that you especially liked (or disliked)?

I loved elementary school and some of my fondest memories are from that time.  I loved all subjects and remember having a ravenous curiosity about everything.  My fourth grade teacher really nurtured my love of fiction writing and often let me write independently or with a friend outside of the classroom.  I loved preparing things for the science fair.

 

8. Did you have chores or tasks that you were regularly expected to do? What were they?

Yard work outside (we had a big property), dishes, cleaning

 

9. Any other recollections of importance that come to mind?

In general, I loved science and writing, as well as fiction books when I was a child.  I come from a musical family and was urged to learn musical instruments when I was little but did not enjoy lessons very much (although I did learn to play the cello in high school and joined a youth orchestra).  Socially, I was many years more mature than my peers beginning in middle school, which was difficult at times.