Results & Screening

Below are the detailed questionnaire and results.

  • Donor Risk Behavior Assessment
  • Fertility History
  • Health History
  • Family Health History

Donor Risk Behavior Assessment

1. Have you had sex with another male in the preceding five years?

Answer: No

2. Have you injected drugs for non-medical reasons in the preceding five years?

Answer: No

3. Have you engaged in sex in exchange for money or drugs in the preceding five years?

Answer: No

4. Have you had sex in the preceding 12 months with a person who would have answered yes to the previous risk items, or with a person known or suspected to have HIV, HBV, or clinically active HCV?

Answer: No

5. Have you been exposed in the preceding 12 months to known or suspected HIV, HBV, or HCV infected blood?

Answer: No

6. Have you been in juvenile detention, lockup, jail, or prison for more than 72 consecutive hours in the preceding 12 months?

Answer: No

7. Have you lived with another person who has hepatitis B or clinically active hepatitis C infection in the preceding 12 months?

Answer: No

8. Within the preceding 12 months, have you undergone tattooing, ear piercing, or body piercing where sterile procedures were not used?

Answer: No

9. Have you had a past diagnosis of clinical, symptomatic viral hepatitis after your eleventh birthday, unless it was identified as hepatitis A, EBV, or CMV?

Answer: No

10. Do you have or suspect that you have sepsis at this time?

Answer: No

11. Have you had a smallpox vaccination in the preceding eight weeks?

Answer: No

12. Have you been diagnosed with clinically recognizable vaccinia virus infection?

Answer: No

13. Have you had a medical diagnosis, illness, suspicion, or confirmed viremia related to West Nile Virus in the preceding 120 days?

Answer: No

14. Have you tested positive or reactive for West Nile Virus infection using a donor screening test in the preceding 120 days?

Answer: No

15. Have you been treated for or had syphilis within the preceding 12 months?

Answer: No

16. Have you been treated for or had chlamydia or gonorrhea infection in the preceding 12 months?

Answer: No

17. Have you or any of your blood relatives ever been diagnosed with Creutzfeldt-Jakob disease?

Answer: No

18. Have you ever been diagnosed with vCJD or any other form of Creutzfeldt-Jakob disease?

Answer: No

19. Have you been diagnosed with dementia or another neurological disease of unknown cause?

Answer: No

20. Have you ever been diagnosed with dementia or any degenerative, demyelinating, or other neurological disease of unknown etiology?

Answer: No

21. Have you received a non-synthetic dura mater transplant, human pituitary-derived growth hormone, or had relevant family history associated with CJD?

Answer: No

22. Have you spent three months or more cumulatively in the United Kingdom from 1980 through 1996?

Answer: No

23. Are you a current or former U.S. military member, civilian military employee, or dependent who resided at certain U.S. military bases in Europe during the listed periods?

Answer: No

24. Have you lived cumulatively for five years or more in Europe from 1980 until present?

Answer: No

25. Have you received any transfusion of blood or blood components in the United Kingdom or France between 1980 and present?

Answer: No

26. Were you or any of your sexual partners born in, or have you or any of your sexual partners lived in, certain listed African countries after 1977?

Answer: No

27. Have you received a blood transfusion or medical treatment involving blood in certain listed African countries after 1977?

Answer: No

28. Have you been the recipient of a xenotransplantation product?

Answer: No

29. Has anyone you have had close contact with been the recipient of a xenotransplantation product?

Answer: No

30. Does your medical history or medical records show any evidence of a diagnosis or prior positive/reactive screening test result for HIV?

Answer: No

31. Have you ever had unexplained weight loss?

Answer: No

32. Have you ever had unexplained night sweats?

Answer: No

33. Have you ever had blue or purple spots on or under the skin or mucous membranes typical of Kaposi’s sarcoma?

Answer: No

34. Have you ever had swollen lymph nodes for longer than one month?

Answer: No

35. Have you ever had an unexplained temperature greater than 100.5°F / 38.6°C for more than 10 days?

Answer: No

36. Have you ever had unexplained persistent cough or shortness of breath?

Answer: No

37. Have you ever had opportunistic infections?

Answer: No

38. Have you ever had unexplained persistent diarrhea?

Answer: No

39. Have you ever had unexplained persistent white spots or unusual blemishes in the mouth?

Answer: No

40. Does your medical history or medical records show evidence of a diagnosis or prior positive/reactive screening test for hepatitis B or hepatitis C?

Answer: No

41. Have you ever had unexplained jaundice?

Answer: No

42. Have you ever had unexplained hepatomegaly?

Answer: No

43. Have you had a past diagnosis of clinical, symptomatic viral hepatitis after your eleventh birthday that was not later identified as hepatitis A, EBV, or CMV?

Answer: No

44. Within the past 120 days, have you experienced unexplained fever, headache, body aches, or eye pain, possibly with rash or swollen glands?

Answer: No

45. Within the past 120 days, have you been diagnosed with severe illness such as encephalitis, meningitis, meningoencephalitis, or acute flaccid paralysis?

Answer: No

46. Within the past 120 days, have you had signs or symptoms of severe illness such as high fever, neck stiffness, coma, tremors, convulsions, weakness, or paralysis?

Answer: No

47. Have you, in the last 12 months, been diagnosed with sepsis or related systemic infection conditions?

Answer: No

48. Have you ever had clinical evidence of infection with two or more unexplained systemic responses to infection?

Answer: No

49. Have you, in the last 12 months, experienced severe signs of sepsis such as unexplained hypoxemia, elevated lactate, low urination, altered mentation, or low blood pressure?

Answer: No

50. Have you, in the last 12 months, had a blood test with a positive blood culture associated with the previous conditions?

Answer: No

51. Does your medical history or medical records show evidence of a diagnosis or prior positive/reactive screening test result for HTLV?

Answer: No

52. Have you ever experienced unexplained paraparesis?

Answer: No

53. Have you ever been diagnosed with adult T-cell leukemia?

Answer: No

54. Have you ever been excluded from blood donation due to history of, or having, infectious disease?

Answer: No

55. Within the previous six months, were you bitten by an animal suspected of having rabies?

Answer: No

56. Do you have a history of Herpes Simplex Virus type 2?

Answer: No

57. Have you had significant exposure to a substance that may be transferred in toxic doses, such as lead, pesticides, asbestos, mercury, or gold?

Answer: No

58. Have you worked in an occupation that put you at increased risk of radiation or chemical exposure, or do you have known history of such exposure?

Answer: No

59. Within the last 12 months, did you receive a blood transfusion?

Answer: No

60. Have any of your sexual partners had a known episode of trichomoniasis?

Answer: No

61. Do you have an infectious skin disease?

Answer: No

62. Have you had more than one sexual partner within the last six months?

Answer: No

63. Do you have a history of alcohol abuse?

Answer: No

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Fertility History

Do you have any children?

Answer: No

Has a woman ever conceived with your sperm?

Answer: No

Have you ever donated sperm before?

Answer: No

Have you ever been refused as a sperm donor?

Answer: No

Have you ever been told that you were infertile?

Answer: No

Has your mother ever had a miscarriage?

Answer: No

Is there any history of infertility problems in your family, including difficulty conceiving or miscarriage?

Answer: No

Personal Health History

Did your parents have difficulty conceiving?

Answer: No

Do any of your brothers have fertility problems?

Answer: No

Did your mother take diethylstilbestrol (DES) or any drugs while she was pregnant with you?

Answer: No

Are you exposed to excess heat, such as sauna, hot tubs, or steam rooms?

Answer: No

Do you wear jockey / brief type underwear?

Answer: No

General Medical History

Have you ever donated blood or plasma?

Answer: No

Have you ever been refused as a blood donor?

Answer: No

Do you currently have any allergies?

Answer: No

Have you ever had surgery?

Answer: No

Vision

How is your vision without contacts or eyeglasses?

Answer: Fair

Do you wear glasses?

Answer: Yes

If yes, at what age?

Answer: 16

Are you nearsighted, farsighted, or other?

Answer: nearsighted

Your vision

Right Eye: 325   |   Left Eye: 200

Your eyeglass prescription

Right Eye: 325   |   Left Eye: 200

Hearing, Dental, and Other Health History

Do you have normal hearing?

Answer: Yes

Condition of your teeth

Answer: Good

Have you ever had braces?

Answer: Yes

Have you had any hospitalization not already mentioned?

Answer: No

Have you ever had major radiation exposure or X-ray exposure?

Answer: No

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The answers below are provided for general transparency. Please confirm all answers are accurate before publishing this page publicly.

Sexually Transmissible Disease History

Have you or any of your sexual partners ever had syphilis?

Answer: No

Have you or any of your sexual partners ever had gonorrhea?

Answer: No

Have you or any of your sexual partners ever had NSU / non-specific urethritis?

Answer: No

Have you or any of your sexual partners ever had chlamydia?

Answer: No

Have you or any of your sexual partners ever had venereal / genital warts?

Answer: No

Have you or any of your sexual partners ever had pelvic inflammatory disease?

Answer: No

Have you or any of your sexual partners ever had herpes?

Answer: No

Have you or any of your sexual partners ever had trichomoniasis?

Answer: No

Have you or any of your sexual partners ever had other sexually transmissible diseases?

Answer: No

General Health History

Have you ever had major illnesses such as amoebic dysentery, hepatitis, pneumonia, mononucleosis, etc.?

Answer: No

Do you have any current or chronic medical problems / conditions?

Answer: No

Have you been bitten by an animal suspected of rabies in the last six months?

Answer: No

Have you ever served in the military?

Answer: No

Did your father serve in the military?

Answer: No

Are you currently taking any medications?

Answer: No

Have you ever taken growth hormone from human pituitary glands?

Answer: No

Have you ever taken insulin from cows / bovine or beef insulin?

Answer: No

Have you ever taken Hepatitis B Immune Globulin after exposure to hepatitis B?

Answer: No

Have you ever taken an unlicensed vaccine?

Answer: No

Have you ever been in juvenile detention or been an inmate of a correctional facility for 72 consecutive hours or longer?

Answer: No

Within the past 12 months, have you been in juvenile detention or been an inmate of a correctional facility for 72 consecutive hours or longer?

Answer: No

Substance Use History

Marijuana

Answer: Never Used

Cocaine

Answer: Never Used

Barbiturates / acid

Answer: Never Used

Narcotics / opiates, including heroin, methadone, opium, morphine, Vicodin, OxyContin, Percocet, codeine, etc.

Answer: Never Used

Amphetamines, including Adderall, Dexedrine, MDMA / ecstasy

Answer: Never Used

Hallucinogens, including LSD, mescaline, mushrooms, peyote

Answer: Never Used

Tranquilizers, including Special K, sleeping pills, Xanax, Valium, or other benzodiazepines

Answer: Never Used

Anti-depressants

Answer: Never Used

PCP

Answer: Never Used

Inhalants, including amyl or butyl nitrate and aerosol propellants

Answer: Never Used

Over-the-counter drugs

Answer: Never Used

Steroids

Answer: Never Used

Others

Answer: Never Used

Alcohol, Smoking, and Caffeine

Do you drink alcoholic beverages?

Answer: No

Approximately how many drinks per week do you consume?

Answer: 0

If you now drink less than 3 drinks per week, was there ever a time when you drank more?

Answer: No

Do you smoke cigarettes?

Answer: No

Do you drink coffee or other caffeinated beverages?

Answer: few

Was your father exposed to toxic chemicals?

Answer: No

Was your father exposed to sprays?

Answer: No

Was your father exposed to fumes or exhaust?

Answer: No

Was your father exposed to radiation?

Answer: No

Was your father exposed to flea powders or sprays?

Answer: No

Was your father exposed to lead or lead products?

Answer: No

Was your father exposed to asbestos or asbestos products?

Answer: No

Was your father exposed to cleaning solutions or solvents?

Answer: No

Was your father exposed to pesticides, herbicides, or fertilizers?

Answer: No

Was your father exposed to petroleum products?

Answer: No

Was your father exposed to any of the above in his living environment, while at work, or while involved in hobbies?

Answer: No

Family Health History

Family Physical Characteristics

Family Member Eye Color Hair Color Complexion Height Body Type Vision
Mother Black Black Medium 5'9" O Excellent
Father Black Black Medium 5'9" A Excellent
Brother Black Black Medium 5' A Excellent

Immediate Family

How many blood siblings are in your immediate family, including yourself?

Answer: 2 males, 0 females

Have twins or multiple births occurred in your family?

Answer: No

Do you have children?

Answer: No

Birth Defects / Family Conditions

Has any member of your family, including yourself, had a problem or defect at birth involving bones, muscles, joints, or limbs?

Answer: No

Has any member of your family, including yourself, had a problem or defect at birth involving the gastrointestinal system?

Answer: No

Has any member of your family, including yourself, had a problem or defect at birth involving the nervous system, brain, or spinal cord?

Answer: No

Has any member of your family, including yourself, had a problem or defect at birth involving the blood or circulatory system?

Answer: No

Has any member of your family, including yourself, had a problem or defect at birth involving the respiratory system?

Answer: No

Has any member of your family, including yourself, had a problem or defect at birth involving an organ such as heart, lung, kidney, etc.?

Answer: No

Has any member of your family, including yourself, had a problem or defect at birth involving the genital or urinary system?

Answer: No

Has any member of your family, including yourself, had a problem or defect at birth involving metabolic conditions such as hormones or enzymes?

Answer: No

Has any member of your family, including yourself, had a problem or defect at birth involving eyes or ears?

Answer: No

Learning, Genetic, and Chronic Conditions

Is there any member of your family who has had or currently has a learning disorder?

Answer: No

Do you have any brothers or sisters who died in infancy or childhood?

Answer: No

Are there any known genetic diseases or conditions that run in your family?

Answer: No

Has anyone in your family, including yourself, experienced recurring and/or chronic physical symptoms that have not been evaluated by a physician?

Answer: No

Family Medical Conditions

Category Conditions Covered Reported Status
Heart Stroke, heart attack, heart disease, hardening of the arteries, high blood pressure N/A / No known family history reported
Blood Anemia, sickle-cell anemia, hemophilia or other bleeding problem, leukemia, immune deficiency, other blood disorder N/A / No known family history reported
Respiratory / Lungs Hay fever, asthma, emphysema, tuberculosis, lung cancer, pneumonia, other lung disease N/A / No known family history reported
Gastrointestinal Stomach or duodenal ulcer, gall stones, hepatitis A, hepatitis B, other liver disease, colon cancer, ulcerative colitis, Crohn's disease, cystic fibrosis, intestinal cancer, rectal disorder, other GI cancer/problem N/A / No known family history reported
Metabolic / Endocrine Diabetes mellitus, hypoglycemia, thyroid cancer, thyroid disease, goiter, adrenal dysfunction or disorder, hyperactivity, hormonal dysfunction or disorder N/A / No known family history reported
Urinary Polycystic kidney disease, other kidney disease, other disease of urinary tract, rectal disorder N/A / No known family history reported
Genital / Reproductive Undescended testicle, hypospadias, prostate cancer, uterine fibroids, ovarian cysts, cancer of cervix, ovaries, or uterus N/A / No known family history reported
Neurological Migraine, intellectual disability, senility before age 50, multiple sclerosis, cerebral palsy, epilepsy, convulsive disorders, hydrocephalus, spinal cord disorders, Huntington's chorea, Gaucher's disease, Wilson's disease, Alzheimer's disease, other nervous system disease N/A / No known family history reported
Mental Health Schizophrenia, manic depressive disorder, other mental health disorders requiring hospitalization N/A / No known family history reported
Muscles / Bones / Joints Muscular dystrophy, other chronic muscle disease, lupus, spine deformity, osteoporosis, dwarfism, hereditary low back disease, arthritis, gout, congenital dislocation of the hip N/A / No known family history reported
Sight / Sound / Smell Deafness before age 60, deformity of the ear, cataracts before age 50, blindness, color blindness, glaucoma, deviated septum, retinoblastoma, congenital word blindness, other sight/sound/smell disorder N/A / No known family history reported
Skin Acne, eczema, skin cancer, pigmentation disorders, other skin disorders N/A / No known family history reported
Other Alcoholism, drug abuse or addiction, breast cancer, other cancer not mentioned above N/A / No known family history reported

Fertility Test Results

Redacted fertility-related test results are embedded below.

Semen Analysis / Fertility Report

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