Oregon Health & Science University                 PROFILE FOR SPERM DONOR      #6497

Andrology/Embryology Lab

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

Portland, OR 97239

Phone:  (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:  The donor’s father (age 80), mother (79), 1 P aunt (83), 2 M uncles (76, 80), 3 brothers (40-59), 1 niece (33), 1 nephew (30) and 2 sons (2, 7) are all living and in good to very good health.  The P aunt has pretty good health although obese, and the oldest M uncle has good health although he has well-controlled diabetes.  Deceased are the PGF (at age 85 of a heart attack or a stroke), the PGM (90, old age), the MGF (80, old age), the MGM (90, old age), a P aunt (80, unknown cause), and 3 P uncles (80 from old age, 80 from unknown cause, 84 from old age).

Donor’s vision:  myopic: -3.0 in left eye, -2.0 in right.

Donor’s hearing:  very good.

Donor’s dental history:  some cavities.

 

 

OCCUPATION:  Executive for national non-profit organization

 

RELIGION:  Christian

 

Sperm Donor Social History:

Recipients are often interested in knowing information about donors' personal interests. Please answer these questions as best as you can: some detail and an attempt to elaborate is appreciated. We may edit your answers for clarity or to protect your anonymity. Thank you.

 

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

 

I have a special talent for music, specifically, jazz flute.  I also enjoy playing classical flute, as well as classical, jazz and popular guitar music.  I play these instruments as well as saxophone and French horn in a military band.  I have a special talent for drawing as well, and I used to draw a regular comic strip for a monthly periodical.

 

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

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

                                                                                                                                               

A talent for mathematics and science runs in my family.  My father has a PhD in physical chemistry.  My nearest-in-age brother has a master’s degree from MIT, and the next oldest brother has a degree in chemistry.  My uncle had a masters degree in physics, and his, son, my cousin, is a very successful physicist with a well known corporation.  I have personally taught basic sciences at the junior college level.

 

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.

                                                                                 

I speak, read and write Japanese.  I have studied Japanese since participating in high school student exchange to that country.  My principle avocation is music.  I play the flute, saxophone, and guitar professionally.  I play trumpet and classical guitar recreationally.  I have done some acting on television commercials.  I enjoy regular physical exercise, and outdoor Scouting activities with my son.  My favorite sport is skiing, and I have also enjoyed foil fencing and skydiving when I was in college.

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

 

I enjoyed biology, literature, history and other social sciences, calculus, physics, organic chemistry, Japanese, and, of course, music.

5. GPA, High School: 3.0                GPA, College:           3.0                   I.Q: unknown

 

SAT combined: 1260           LSAT: 670 (96th %ile)            MCAT: 30-S    AFQT: 99th %ile

 

6. How would you describe your personality characteristics?

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

 

I am intuitive and cerebral.  I enjoy public speaking.  I would describe myself as charming and somewhat funny, as well.

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

 

I have always been interested in medical science, and I want to participate in helping others achieve their dreams of having a family.  This is something I have always wanted to do

Additional Descriptive Characteristics:

 

Handedness: Right/Left/Ambidextrous

 

Right

 

Foot/Shoe Size:

 

11.5

 

Hairy Chest: YES/NO

 

No

 

Hairy: YES/NO

 

No

 

Beard Color:

 

Dark blond

 

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

No.

Acne problems:

No.

 

Reactivity/Sensitivity to sun exposure:

 

I have normally fair skin.

 

Donor Family Social History:                                                                                                 

	Education	Occupation	Interests	Eye color	Hair color	Height	Body Type
PGF	college	minister	Evangelism, carpentry	blue	brown	>6’	slender
PGM	College	Minister’s wife	writing	blue	brown	?	?
MGF	college	Soldier, Indian Service land manager	unknown	unknown	unknown	~6’	slim
MGM	Unknown	unknown	unknown	unknown	unknown	?	?
Father	PhD	Physical chemist	Painting, music, skiing, fencing	blue	Grey (brown)	6’ 5”	Slender
Mother	college	school teacher	Reading, gardening	Hazel	Grey (Brown)	5’ 11.5”	slim
Brother	MBA	Computer programmer	Running, writing	blue	Blond	6’ 5”	Slender
Brother	college	USMC fighter pilot, Airline pilot	Politics	blue	Blond	6’ 3”	athletic
Brother	College	unknown	unknown	Brown	Brown	6’ 5”	heavy
P Uncle	college	Minister	Theology, history, Aramaic	blue	Blond	6' 4"	Thin
P Uncle	College	Social worker	Painting	Blue	Blond	6’ 2”	Thin
P Uncle	MS in physics	Physicist	Travel	blue	brown	~6’	athletic
P Aunt	College       ?	Homemaker	Swimming	blue	unknown	unknown	slender
P Aunt	college	Homemaker	Painting	Blue	Blond	5’ 11”	Over-weight
M Uncle	College	accountant	unknown	Blue	Brown	6’ 2”	slim
M Uncle	College	Business owner	Unknown	Blue	Brown	6’	slim
Your child	Japanese immersion school	study	Basketball, Pokémon, Japanese	Brown (half-Asian)	brown	48”	athletic
Second Child	Pre-school	play	Thomas the Tank Engine	Hazel (half-Asian)	auburn	36”	normal

 

Comments about or additions to your family history:

 

My nearest-in-age brother’s wife is now pregnant.

  Psychological Assessment and Comments from Paula Acker LCSW, an independent Psycho Social Counselor, following an Interview with donor 6497:

 

Referral Information:  Donor #6497 was referred to this office for a psychological evaluation to be an anonymous donor for Oregon Health and Sciences University Fertility Consultants.  Prior to this evaluation he had a medical evaluation and screening at OHSU.  This evaluation was done as a face to face in depth interview following the guidelines of the American Society of Reproductive Medicine Mental Health Professional Group recommendations for screening anonymous donors. This evaluation included the PAI psychological testing and the results will follow in this report.

 

Motivation for Donation:  Donor is a Caucasian married father of two sons.  He states his motivation to be an anonymous donor is to help other family oriented people to achieve parenthood.  He is also interested in the science of conception and finds this a wonderful opportunity to help others.  He is completely open to donating to all individuals or couples that are interested and ready to start a family, whether they are single woman, same sex couples, or heterosexual couples.

 

Informal Mental Status and Behavioral Observations:  Donor # 6497 was on time to this appointment and appropriately dressed. He had come in directly from work so was dressed in a business suit.  He was very intelligent and personable in his responses to the interview questions, and had excellent eye contact.  He was oriented to person, place and time and did not display any cognitive deficits.  His disposition was caring and warm.  His affect was appropriate to the discussion. This donor is a very attractive man with clear blue eyes, a perfect smile, and flawless skin. 

 

Brief Psychological History:  Donor grew up on the east coast and moved to Oregon about seven years ago.  His father is an eighty year old retired man and had previously been a chemical engineer.  He is still in excellent health. His mother is seventy nine years of age and had worked as a substitute teacher. She also is in excellent health.  Donor is the youngest of four sons.  His oldest brother is fifty nine and an airline pilot, healthy with a son and a daughter.  His next brother is fifty six and works in the computer hardware field. He has no children and is healthy. His other brother is forty years of age, healthy, has an MBA from MIT, and has no children.  There are a lot of boys in his family of origin and very few girls that have been born.  Donor has been married for eight years and has two sons ages seven and three. He works full time for a national youth service organization. His wife works full time as a medical researcher.

 

Brief Psychological Family History:  There is no history of mental illness in the family of origin and Donor #6497 has never sought counseling support. He has no history of depression or needing psychiatric medication.  There is no history of alcoholism in the family of origin. Donor #6497 is a non-drinker and non-smoker.  He does not use recreational drugs he reports. He has had no recent unanticipated loss or grief.  He has no legal or financial concerns and no bankruptcies.  His wife is supportive of him being an anonymous donor for OHSU. 

 

Hobbies and Interests:  Donor is a musician and plays for established bands.  He plays many different instruments including French horn, flute, cello, alto sax, and the piccolo.  He also enjoys outdoor pursuits with his sons and his youth groups.

 

Psychological Testing Results:  The PAI clinical profile reveals no evaluations that indicate the presence of clinical psychopathology.  The entire tests were in the normal limits and did not see any concerns with hostility, elevated mood or marked anxiety, or depressive issues. In addition the PAI test did not report any problems with drugs or alcohol issues or dependency. It did show that he has a positive self image and that he approached life with a clear sense of purpose. 

 

Recommendation:  Donor is interested in being an Information Release Donor. He has carefully considered all aspect of being an anonymous donor and is volunteering to do this of his own free will without undue influence from anyone else. He feels comfortable passing on his genetic contributions to those that desire to become parents.  He did not demonstrate any excessive emotional attachment to his genetic contribution or any potential resulting offspring.  His personal and familial mental health histories fall in the recommended guidelines by the American Society of Reproductive Medicine Mental Health Professional Group along with the clinical interview and testing he is recommended as a donor for OHSU.

 

Paula Acker LCSW

Licensed Clinical Social Worker

 

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?

 

I was born in New England, where my father was working for a chemical company.  I grew up in a CT suburb of New York.  It was fairly rustic at that job, and a very nice place to grow up.  My family did not move at all when I was growing up.  I had three brothers, but only grew up with one, the other two being older.  We had and continue to have a close relationship.

 

 

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.

 

No, not regular contact.  Our extended family all lived in other parts of the country.

 

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

   

Food(s):         jalapeno and cream cheese on toast.  I preferred spicy, sour foods

   

Colors(s):       blue.
              

Toy(s):            legos, Lincoln logs, baseball and glove, erector set

Indoor Game(s):       Indoor game(s)? Chess & judo. 

   

Outdoor Game(s):    dodge-ball, baseball and football

Book(s):                     Curious George.

Sports(s):                   baseball, soccer, judo

Other Activity(s):       Cross-country/downhill skiing, biking, skateboarding, and playing the trumpet.
 

4. What is your earliest memory?

 

I can remember once having my diaper changed at day care.  I must have been younger than four.  I can’t remember anything else until I got my first pair of cap guns at age 4.

5. What did you do during the summers?

 

Road trip across the country – staying with family or camping at the KOA, swimming, baseball.  Summer camp
 
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.

 

Many new technologies emerged during my childhood.  We were among the first families in our area to have a computer at home, and we played games on it before video games were common place.  I can remember when headphones were enormous and I remember when push button phones and microwaves became popular.

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)?

 

In fourth grade, I was considered the smartest kid in school.  I was placed in a program for the gifted, which I enjoyed.  In high school, I had an army veteran chemistry teacher whom we all liked very much. 

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

 

Of course, I had to clean my room and make my bed.  My personal task was to feed our cats.  I also remember chopping wood, mowing the lawn, washing the car, and being an extra pair of hands for my dad.

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

 

I had a precocious talent for graphic art when I was very young, drawing in three dimensions at an early age.