March 8, 2016
DONOR PROFILE #417
DEMOGRAPHIC AND PHYSICAL DATA
Place of Birth: Great Neck, NY
Birth Date: November 1989
Race: Caucasian
Religion: Jewish/Christian
Ethnic Origin: (Maternal): Polish, German
Blood Type: O +
Height: 6’0”
Weight: 200 lbs
Body Frame: Medium
Complexion: Fair-Medium
Hair Color: Light Brown
Hair Type: Straight
Eye Color: Blue
(Paternal): Irish, British
PERSONAL/EDUCATIONAL HISTORY
Marital Status: Single
Education: BA/Phd Candidate
No. of Children: None
Occupation: Math Tutor
No. of Siblings: None
Career Goals: Psychologist in private practice
Hobbies/Interests: Sports, reading, fiction, music, socializing, yoga and singing.
Describes himself as: Easy going, relaxed but can assert myself when necessary, organized, caring, compassionate and friendly.
PERSONAL FAMILY BACKGROUND
Age
HT
WT
Cplx
Height
Weight
Complexion
Mother
61
5’ 5”
140 lbs
Med
Father
61
6’0”
175 Ibs
Med
Hair/Eye
Color
Educ/Occup
Brn/Brn
PhD/School
Psychologist
LtBrn/Brn
SIB(F)
33
5’5”
135 lbs
Decd
Cause
of
Death
-
MD/
Neuphrologist
Med
Brn/Blu
MA/ Teacher
/RE Agent
5’3”
150 lbs
Med
Brn/Brn
5’10”
160 lbs
Fair
Brn/Brn
HA
NC
Stroke
MGM
MGF
5’4”
120 lbs
Med
Brn/Brn
5’7”
180 lbs
Med
Brn/Brn
PGM
PGF
Govt
Employee
NC
KEY:
AVG: Average BA: Bachelor of Arts BLK: Black BLU:Blue BRN: Brown HA: Heart Attack HS:High School MA: Master of Arts
MD: Doctor of Medicine MED: Medium MGF: Maternal Grandfather MGM: Maternal Grandmother NC: Natural Causes
PGF: Paternal Grandfather PGM: Paternal Grandmother PhD: Doctor of Philosophy RE: Real Estate Sib: Sibling
DONOR PROFILE#: 417
DONOR/FAMILY MEDICAL HISTORY
Medical Problems
Donor
Relative
Circulatory (Blood/Heart)
None
MGF: HA
MGM: Stroke
Gastrointestinal
None
None
Genital/Reproductive
None
None
Integumentary (Skin)
None
None
Mental Health
None
None
Metabolic/Endocrine
None
None
Musculo/Skeletal
(Muscles/Bones/Joints)
None
None
Neurological
None
None
Respiratory (Lungs)
None
None
Sight/Sound/Smell
None
Urinary
None
None
Allergies
None
None
Birth Defects
None
None
Genetic Diseases
None
None
Other
None
None
MO & FA: Reading Glasses
DONOR GENETIC SCREENING RESULTS
Canavan Disease: Negative
Hemoglobinopathies: Hemoglobin electrophoresis, normal
Chromosome Analysis: Male Karyotype
SMA: Non-carrier
Cystic Fibrosis: Tested for 99 mutations, negative for all.
Familial Dysautonomia: Negative
Gaucher Disease: Negative
Tay-Sachs Disease(DNA): Non-Carrier
Thalassemia: CBC/DIFF within normal limits, MCV normal.
PSYCHOLOGICAL SCREENING: The donor meets all of our criteria for participation in our anonymous
donor program including psychosocial history and current state of functioning.
OTHER: Sings and plays the piano.