Medical information
Health and test results
This page contains the complete self-reported questionnaire and fertility report. Review all medical information with a qualified professional.
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
Fertility & personal health
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
Lifestyle & general health
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.