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Free Sperm Donor - Northern California / San Francisco Bay Area |
Medical History
For the lifestyle questionnaire, see http://trentdonor.org/screening
For STD results and Physical Exam Results, see http://trentdonor.org/std
Below is a questionnaire and information regarding Trent's medical history and may be reviewed by a recipient and their physician:
List significant medical surgeries and diseases since childhood:
| Age | Event |
| Age 0 | Appendectomy (see Dr's report) |
| Age 5 | Chicken Pox (varicella-zoster virus) contracted with typical recovery. |
| Age 8 | Fractured right tibia (broken leg ice skating). |
| Age 13 | Began orthodontics program to treat crowding of upper teeth. |
| Age 17 | Wisdom teeth extraction. |
Have you or anyone in immediate family been diagnosed with any of the following?:
| Trent's Answer | |
| _ YES √ NO | Autism |
| _ YES √ NO | Allergies of any type, including dust, pets, pollen, mold |
| _ YES √ NO | ADHD |
| _ YES √ NO | Alzheimer's disease |
| _ YES √ NO | Asthma |
| _ YES √ NO | Chronic Depression |
| _ YES √ NO | Chronic Fatigue |
| _ YES √ NO | Crohn's Disease |
| _ YES √ NO | Diabetes |
| _ YES √ NO | Hypertension |
Yourself or any immediate family members known to have any of the following genetically inherited disorders?:
| Trent's Answer | |
| _ YES √ NO | Down Syndrome |
| _ YES √ NO | Spina bifida |
| _ YES √ NO | Anencephaly (born without a skull or partial skull) |
| _ YES √ NO | Bleeding disorders, hemophilia |
| _ YES √ NO | Cystic fibrosis |
| _ YES √ NO | MS |
| _ YES √ NO | Sickle cell anemia |
| _ YES √ NO | Heart defect at birth |
| _ YES √ NO | Tay Sachs diease |
| _ YES √ NO | Huntington's Disease |
| _ YES √ NO | Cystic Fibrosis |
Are you aware of any of the following birth related conditions occurring with immediate family members:
| Trent's Answer | |
| _ YES √ NO | Stillbirth |
| _ YES √ NO | Prematurity |
| Additional Comments: |
"Mother gave birth to all three children at exactly 9 months through vaginal delivery, with each child weighing between 8-10 lbs. There have been twins boys in Trent's extended family." |
Please list any additional known health conditions family members who have died:
| Trent's Answers | |
| "Maternal grandfather survived a heart attack in his 50's and possibly sustained a heart attack when drowning in his 70's" |
| For Latest Physical Exam, See the STD Results Page | Fitness Profile Page 1 | Fitness Profile Page 2 | Fitness Profile Page 3 | Fitness Profile Page 4 | Fitness Profile - All 4 Pages |
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PDF File (Pages 1-4)
(administered by an NASM Certified Personal Trainer) |
ECG and Echocardiograms:
| Date | Test | Ejection Fraction (EF) | Fractional Shortening (FS) | JPG Source | PDF Source |
| 05-Oct-2006 | Echocardiogram (ECHO) | 72% | 42% |
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Echo - Page 1 Echo Page 2 |
Echo - PDF File (2 pages) |
| 05-Oct-2010 | Echocardiogram (ECHO) | 71% | 40% |
![]()
Echo - Page 1 Echo Page 2 |
Echo - PDF File (2 pages) |
| 01-Oct-2010 | Electrocardiogram (ECG) | - | - |
![]() ECG Pg 1 of 1 |
ECG - PDF File (1 page) |
Vision Exam:
Articles
| Article | Quote |
| Understanding Ejection Fraction - Barnes Jewish Hospital |
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| Ventricle (Heart) - Wikipedia |
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