Oregon Health & Science University PROFILE FOR SPERM DONOR #6371

Andrology/Embryology Lab

3303 S.W. Bond Ave., 10^th floor

Portland, OR 97239

Phone: (503) 418-3700

PHYSICAL CHARACTERISTICS

Height: 6’ 1”	Weight: 165	Hair Color: Light Brown
Eye Color: Blue	Hair Type: Straight, Slightly Wavy	Complexion: Fair
Race: Caucasian	Mother=s Ethnic Background: German Father=s Ethnic Background: German, Austrian
Blood Type: O +

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.

Alcoholism:	Edema:	Mental disorders:
Allergy:	Emphysema:	Mental retardation:
Anemia:	Epilepsy:	Miscarriages:
Asthma:	Glaucoma: MGM	Stillbirths:
Blindness:	Goiter:	Migraine:
Cancer:	Gout: MGF	Muscular dystrophy:
Cataracts: PGF	Heart attack:	Myasthenia gravis:
Cirrhosis:	Heart disease:	Paraplegia:
Cleft palate or lip:	Hemophilia:	Parkinson=s:
Club foot:	Hermaphroditism:	Psoriasis:
Color blindness:	Hernia, inguinal:	Sickle cell anemia:
Cystic fibrosis:	Huntington=s chorea:	Tay Sachs disease:
Deafness:	Hypertension:	Thalassemia:
Diabetes: Paternal First Cousin	Jaundice:	Undescended testicles:
Dislocated hip:	Juvenile arthritis:
Eczema:	Lymphedema:

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: The donor’s father (age 55), mother (47), PGF (92), MGM (80), 3 P aunts (50, 61, 65), 1 P uncle (59), 2 M aunts (52, 62), 3 M uncles (45, 50, 55), and 1 sister (21) are all living, fit, and in good health with exception of the PGF (physically healthy, deteriorating memory). Deceased are the PGM at age 70 (stroke and atherosclerosis, was obese) and the MGF at 82 (kidney failure).

Donor’s vision: 20/30 uncorrected, both near and far, astigmatism

Donor’s hearting: good.

Donor’s dental history: good.

EDUCATION:	Subject of study	Type of University
> 1 year college
Baccalaureate Degree	B.A. (Chemistry)	Private university
Master=s Degree
Professional Degree

OCCUPATION: Post baccalaureate student, science-related

RELIGION: None

Social History:

1. Do you have any special talents?

Athletics: long distance running, cycling, alpine climbing.

Music: guitar, harmonica, singing.

Also adept at cooking, gardening, woodworking.

2. Are there any special talents that seem to run in your family? (athletics, music, artistic, etc.)

Cooking: father, mother, sister.

Music: father, sister.

Athletics: father, sister.

3. What are your interests and hobbies?

Mountain biking: intermediate, 1-2 times per week during the summer.

Road biking: intermediate, 2-3 times per week in summer.

Skiing: recreational, once every other weekend.

Mountain climbing: advanced, have summited almost all of the cascades including Mt. Rainier, Mt. Hood, Mt. Jefferson.

Rock climbing: intermediate.

Surfing: recreational.

Cooking: recreational, I enjoy trying anything new.

Hiking/climbing: intermediate.

Woodworking: recreational.

Music: intermediate, now music is just a recreational thing for me, but I used to compete in a number of different choirs in high school.

Travel: recreational, as much as my budget will allow.

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

Chemistry, biology, moral/ethical philosophy.

5. High School GPA 4.0 College GPA 3.75 I.Q. Unknown

6. How would you describe your personality characteristics?

Optimistic, funny, easy-going, thoughtful, witty, autonomous, practical, adventurous, generous, honest, rational, resourceful, resilient, an overall zest for life.

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

It’s a great opportunity to help and affect others in a very big way.

Additional Descriptive Characteristics:

Handedness: Left Foot/Shoe Size: 11

Hairy Chest: Yes Hairy: No Beard Color: Light Brown

Any Distinguishing Features (Dimples, Cleft Chin, Roman Nose, Freckles, etc.):

Slight dimples.

Acne problems:

No

Reactivity/Sensitivity to sun exposure:

No

Do you smoke? No

Family Social History:

	Education	Occupation	Interests	Eye color	Hair color	Height	Body Type
PGF	high school	farmer	hunting, farming	blue	brown	6’1”	thin
PGM	high school	stay at home mom	sewing, cooking, gardening, games	blue	blond	5’4”	average
MGF	high school	farmer	hunting, farming, fishing	blue	blond	5’10”	average
MGM	high school	stay at home mom	gardening, cooking, antiquing, volunteering with church, crafts	blue	blond	5’6”	thin
Father	vocational school	carpenter, farmer	fishing, hunting, cooking, gardening, woodworking	blue	brown	5’10”	thin
Mother	high school	rural postal carrier	gardening, antiquing, cooking, volunteering	blue	blond	5’9”	thin
Sister	enrolled in grad school	student of psychology	piano, cooking, crafts, snowboarding	blue	blond	5’7”	average
Cousin	Bachelors	teacher	piano, volunteering, traveling, antiquing	blue	auburn	5’5”	slender
Aunt	cosmetology school	cosmetologist	gardening, socializing, antiquing, music	blue	blond	5’7”	thin
Aunt	vocational school	crisis counselor	gardening, music	blue	brown	5’9”	thin
Uncle	high school	carpenter	woodworking, auto repair	blue	brown	6’3”	thin
Uncle	Bachelors	accountant	volunteering at church, reading	blue	brown	5’9”	thin

Comments Following an Interview with Paula Acker LCSW Clinic Counselor:

Donor 6371 psychological assessment:

Referral Information: Donor is a Caucasian man who was referred for a psychological assessment to be an anonymous sperm donor for OHSU Fertility Consultants. This in depth evaluation followed the guidelines of the American Society of Reproductive Medicine Mental Health Professional Group recommendations for screening anonymous donors and includes the PAI psychological testing with results to follow in this report.

Motivation for Donation: Donor states his motivation to become a donor was initially for financial reasons as he is a graduate student and does not have a lot of money. However he also believes this is doing a good “deed” by helping those who desire to have children by donating his sperm. He is engaged to be married and his fiancé is supportive of his participation and thinks it is a very good idea to do this. They hope to have children in the future and he has a close relationship with his own family.

Informal Mental Status and Behavioral Observations: Donor was on time to this appointment and appropriately dressed. His mannerisms and language were in the normal range and he did not display any cognitive abnormalities. He was thoughtful in his responses to questions asked and interested in learning more about the psychological impact of infertility on couples and how they chose third party reproduction as their family building option. He has a very upbeat personality and was very warm and engaging. He appears to be an extremely intelligent young man and is quite mature for his age. This donor makes a very positive first impression and has a handsome face and beautiful smile with sparkling white straight teeth.

Psychosocial History: Donor grew up in the Midwest and has been in Oregon attending graduate school in the medical field. His father is a carpenter that is highly skilled. His mother is a postal carrier. He states both parents are very healthy. Donor has one sister and she recently graduated from college with a BA in Psychology. She is planning on continuing her education to gain a Masters Degree in Counseling Psychology and wants to counsel teenagers. She is single with no health problems. Donor states she is very healthy. He has two years of graduate school left.

Psychological History: Donor states there is no history of mental illness in his family of origin and he has never sought counseling or suffered from any depression. There is no history of alcoholism he reports in his family of origin. He is a social drinker averaging one beer in the evenings when he cooks dinner. He has no legal or financial problems and has never had a bankruptcy. He states to not being a recreational drug user and has no history of substance abuse. He has no unanticipated loss and grief although he is saddened by the late stage illness of his maternal grandmother. He is a non-smoker. Donor describes his personality as friendly, outgoing and very even tempered.

Hobbies and Interests: Donor is an avid outdoorsman. He has climbed fifteen mountains in the Pacific Northwest in the last year and a half! He also likes canoeing, running and is an avid mountain biker. He recently took up photography.

Results of the PAI testing: Donor took the PAI and did not show any signs of psychopathology in the clinical scales. His entire results were in the normal limits. He described no significant problems with empathy, unusual thought patterns, antisocial behaviors, hostility, moodiness, impulsivity, unhappiness or depression. He also reports no problems with alcohol or drug dependency. His self report shows a positive self motivated individual who is adaptive and self satisfied in his life. He is characterized as friendly and extraverted. He prefers activities with others and quick to offer help to those who need it.

Recommendation: Donor meets the ASRM Mental Health Professional Group recommendations for anonymous donors and along with the results of the clinical interview and the results of the PAI testing is recommended as an anonymous donor for Oregon Health and Sciences University Fertility Consultants.

Paula Acker LCSW

Licensed Clinical Social Worker

KID PAGE

1. In general, please describe your childhood.

We lived in the same home my entire childhood through teens and my parents still live there today. I have very fond memories of our home. It is a very secluded farm where I spent a lot of my time as a child exploring the great outdoors. I have one sister two years younger than myself and we spent a lot of time playing together. Since we lived so far away from town, we ended up becoming very close.

2. Were there any family members other than your parents and siblings with whom you regularly had contact?

We did spend quite a bit of time at my dad’s parent’s house when we were young. They lived down the same road as we did and my sister and I spent a lot of time with them playing games and also helping them with chores.

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

Food(s)? Apple pie: my parents have a lot of apple trees at their home and my mom perfected the apple pie.

Color(s)? Red, and it still is today.

Toy(s)? When I spent time inside my favorite was Lego’s.

Indoor game(s)? When we were old enough we played a lot of monopoly as a family.

Outdoor game(s)? Hide and seek, with a farm you can play for hours.

Book(s)? I remember reading the book Hatchet by Gary Paulsen. I wanted to be the boy stranded in Canada after that.

Sport(s)? Basketball, my dad would play with me a lot when he came home.

Other activity(s)?

4. What is your earliest memory?

My earliest memory is of all of my cousins and extended family getting together at my aunts home and swimming in the river in her backyard.

5. What did you do during the summers?

We spent a lot of time with my mom since she would take summers off to stay with us. Also, living on a farm, once we were old enough we would help with chores that were suitable. Also I remember always looking forward to bible camp every summer. My sister and I loved going, and I’m sure my parents liked it too.

6. Are there any Anew@ 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?

I remember one of my older cousins having an Atari video game system that was the coolest thing I had ever seen. I think I begged my parents for a Nintendo for a long time after seeing that. My parents weren’t big video game fans so I really enjoyed getting to stay with friends who had them. It’s amazing to see how different video entertainment has changed since then.

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 did enjoy school a lot as a child, but probably more for the socializing than the learning since it was really my only time to interact with children outside my family. I do remember my fourth grade teacher who was a great help to me, especially in getting me orientated toward learning and not playing too much with classmates.

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

It’s hard for me to specifically think of individual tasks that we were asked to do, but I do remember helping my dad out a lot on the farm when I was old enough. I remember that once I hit a certain age my dad would wake me up and have me come out with him in the morning to feed and milk the cows and then do the same in the evening. Also when I became older still my dad would give me more responsibilities in that I was accountable for certain tasks that needed to be done which I really didn’t like at the time, but I feel has definitely shaped who I am today.

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