Male Donor Profile
Please e-mail completed form to .
Date of birth
Height / --choose--456 feet --choose--1234567891011 --choose--exactly1/41/23/4 inches
Weight / pounds
Ethnicity/race (fill in all that apply) / --choose--whiteblackHispanicAsianPacific IslanderAmerican IndianAlaskan Native --choose--AfricanArabic or PersianAustralianCanadianChineseDutch (Netherlands)EnglishFilipinoFrenchGermanIndian, NOT Native AmericanIrish/ScottishItalianJapaneseKoreanMexicanNative American IndianNorwegianRussian/Czech/SlovakianSpanish (Spain)SwedishSwissVietnameseDon't Know --choose--AfricanArabic or PersianAustralianCanadianChineseDutch (Netherlands)EnglishFilipinoFrenchGermanIndian, NOT Native AmericanIrish/ScottishItalianJapaneseKoreanMexicanNative American IndianNorwegianRussian/Czech/SlovakianSpanish (Spain)SwedishSwissVietnameseDon't Know --choose--AfricanArabic or PersianAustralianCanadianChineseDutch (Netherlands)EnglishFilipinoFrenchGermanIndian, NOT Native AmericanIrish/ScottishItalianJapaneseKoreanMexicanNative American IndianNorwegianRussian/Czech/SlovakianSpanish (Spain)SwedishSwissVietnameseDon't Know --choose--AfricanArabic or PersianAustralianCanadianChineseDutch (Netherlands)EnglishFilipinoFrenchGermanIndian, NOT Native AmericanIrish/ScottishItalianJapaneseKoreanMexicanNative American IndianNorwegianRussian/Czech/SlovakianSpanish (Spain)SwedishSwissVietnameseDon't Know
If Native American, what tribe? / What percent: --choose--100%75%50%25%0.125% (1/8)0.0625% (1/16)Don't Know
Hair color / --choose--Light BlondeMedium BlondeDark BlondeLight BrownMedium BrownDark BrownBlackRedLight AuburnMedium AuburnDark AuburnOther if other, list:
Eye color / --choose--Light BlueMedium BlueDark BlueLight GreenMedium GreenDark GreenLight BrownMedium BrownDark BrownHazelOther if other, list:
Skin complexion/tone / --choose--FairMediumDarkOlive
Skin: freckles / --choose--YesNo
Blood type / --choose--O PositiveO NegativeA PositiveA NegativeB PositiveB NegativeAB PositiveAB Negative
Body build / --choose--Small/PetiteMediumLargeOther if other, list:
Highest level of education / --choose--Middle SchoolHigh SchoolAssociate's DegreeBachelor's DegreeMaster's DegreeDoctorateMDTechnical Certification What was your major:
Current occupation
Previous work history
Military service / --choose--ArmyAir ForceCoast GuardMarinesNational GuardNavy --choose--Active DutyReservesRetired Number of years served:
health history
Vision without correction / Right eye: Left eye:
Hearing impairment / Right ear: --choose--NoneRingingPartial Deafness, born withPartial Deafness, acquired medicallyPartial Deafness, acquired by injuryDeaf, born withDeaf, acquired medicallyDeaf, acquired by injury Left Ear --choose--NoneRingingPartial Deafness, born withPartial Deafness, acquired medicallyPartial Deafness, acquired by injuryDeaf, born withDeaf, acquired medicallyDeaf, acquired by injury
Dental / --choose--Excellent: no tooth decay or fillingsGood: normal tooth decay, filled cavitiesFair: crowns, root canalsPoor: excessive tooth decay, missing teethGingivitis or other gum diseaseExtra TeethOther if other, list:
Diet / --choose--NormalVegetarianVeganOther if other, list:
Dietary restrictions / --choose--YesNo if yes, list:
Dietary supplements / --choose--YesNo if yes, list:
Exercise / --choose--YesNo if yes, list:
Surgical history / --choose--YesNo if yes, list:
Major X-ray or radiation exposure / --choose--YesNo if yes, list:
Exposure to herbicides/toxic chemicals / --choose--YesNo if yes, list:
Smoker / --choose--YesNo if yes, how many per day:
Tattoos / --choose--YesNo if yes, list:
Alcohol consumption / --choose--YesNo if yes, how much:
Recreational drug use (cocaine, marijuana) / --choose--YesNo if yes, list:
Blood transfusion within past 12 months / --choose--YesNo if yes, list:
Ever told could not donate blood / --choose--YesNo if yes, explain:
Currently on medications / --choose--YesNo if yes, list:
Allergies to medications / --choose--YesNo if yes, list:
UC Center for Reproductive Health
male Donor Form
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Last modified on: 9/11/2014, 11:36:54 AM
UC Health Center for Reproductive Health
have You been treated for the following:Allergies / --choose--YesNo if yes, list:
Alcohol Abuse / --choose--YesNo if yes, list:
Anxiety / --choose--YesNo if yes, list:
Arthritis / --choose--YesNo if yes, list:
Asthma / --choose--YesNo if yes, list:
Autoimmune disease / --choose--YesNo if yes, list:
Bleeding disorders / --choose--YesNo if yes, list:
Birth defects / --choose--YesNo if yes, list:
Cancer / --choose--YesNo if yes, list:
Chronic health problems / --choose--YesNo if yes, list:
Clubfeet / --choose--YesNo if yes, list:
Congenital hip dislocation / --choose--YesNo if yes, list:
Crohn’s disease / --choose--YesNo if yes, list:
Depression / --choose--YesNo if yes, list:
Diabetes / --choose--YesNo if yes, list:
Drug abuse / --choose--YesNo if yes, list:
Epilepsy / --choose--YesNo if yes, list:
Gastrointestinal problems / --choose--YesNo if yes, list:
Growth hormone treatment / --choose--YesNo if yes, list:
Hearing problems / --choose--YesNo if yes, list:
Heart problems / --choose--YesNo if yes, list:
Hepatitis / --choose--YesNo if yes, list:
High blood pressure / --choose--YesNo if yes, list:
High cholesterol / --choose--YesNo if yes, list:
Irritable bowel / --choose--YesNo if yes, list:
Kidney disease / --choose--YesNo if yes, list:
Lactose intolerance / --choose--YesNo if yes, list:
Mania / --choose--YesNo if yes, list:
Migraine headache / --choose--YesNo if yes, list:
Mononucleosis / --choose--YesNo if yes, list:
Neurofibromatosis / --choose--YesNo if yes, list:
Neurological disorders
(degenerative or infectious) / --choose--YesNo if yes, list:
Pneumonia / --choose--YesNo if yes, list:
Psychiatric problems / --choose--YesNo if yes, list:
Schizophrenia / --choose--YesNo if yes, list:
Sickle cell disease / --choose--YesNo if yes, list:
Skin problems / --choose--YesNo if yes, list:
Thalassemia / --choose--YesNo if yes, list:
Ulcerative colitis / --choose--YesNo if yes, list:
Visual problems / --choose--YesNo if yes, list:
UC Center for Reproductive Health
male Donor Form
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Last modified on: 9/11/2014, 11:36:54 AM
UC Health Center for Reproductive Health
Your reproductive historyHow many children by any partner
Treated for a sexually transmitted disease / --choose--YesNo if yes, explain:
Treated for infertility / --choose--YesNo if yes, explain:
Your personal information
Birthplace
Hometown/where you grew up
Wore braces / --choose--YesNo
Handedness / --choose--Right-handedLeft-handedAmbidextrous
Math skills/ability
Mechanical skills
Favorite sport
Athletic skills
Favorite music
Musical skills
Favorite movie
Favorite book
Literary skills
Hobbies/talents
Artistic abilities
Languages spoken
(check all that apply): / English Spanish French German Italian Japanese
Chinese Vietnamese Russian Farsi Arabic Other
Favorite foods
Favorite color
Favorite pets
What specifically would you want the recipient to know about you?
Motivation to donate
UC Center for Reproductive Health
male Donor Form
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Last modified on: 9/11/2014, 11:36:54 AM
UC Health Center for Reproductive Health
Your sexual activity historySexual orientation / --choose--Heterosexual - opposite sexBi-sexual - same and opposite sexGay - male to maleLesbian - female to femaleAbstinent - no sexual activity
Number of partners within last 5 years
Number of partners within last 12 months
Types of birth control used / --choose--PillsIUDRingDiaphragmSpermicideCondomPatchOther if other, list:
Currently more than one sexual partner / --choose--YesNo
Engaged in sex for exchange of money / --choose--YesNo
Engaged in sex with HIV(+) or IV drug user / --choose--YesNo
Casual sexual contact with persons you do not know / --choose--YesNo
Sexual practices include ejaculation of semen / --choose--YesNo
Sexual practices include the exchange of body fluids other than semen (ie, urine, feces) / --choose--YesNo
Sexual practices include anal penetration/stimulations with penis, tongue or objects (or has in the past) / --choose--YesNo
Any sexual partners had symptoms of infections or recurring problems such as richomones, Chlamydia, bladder infection, herpes / --choose--YesNo
Any sexual partners in the last five years been sexually active with anyone in the high risk group for AIDS / --choose--YesNo
Your Family History
Mother / Father
Ethnicity/race / --choose--whiteblackHispanicAsianPacific IslanderAmerican IndianAlaskan Native --choose--AfricanArabic or PersianAustralianCanadianChineseDutch (Netherlands)EnglishFilipinoFrenchGermanIndian, NOT Native AmericanIrish/ScottishItalianJapaneseKoreanMexicanNative American IndianNorwegianRussian/Czech/SlovakianSpanish (Spain)SwedishSwissVietnameseDon't Know / --choose--whiteblackHispanicAsianPacific IslanderAmerican IndianAlaskan Native --choose--AfricanArabic or PersianAustralianCanadianChineseDutch (Netherlands)EnglishFilipinoFrenchGermanIndian, NOT Native AmericanIrish/ScottishItalianJapaneseKoreanMexicanNative American IndianNorwegianRussian/Czech/SlovakianSpanish (Spain)SwedishSwissVietnameseDon't Know
Date of birth
Medical conditions
Living? / --choose--YesNo if no, list cause: / --choose--YesNo if no, list cause:
Hair color / --choose--Light BlondeMedium BlondeDark BlondeLight BrownMedium BrownDark BrownBlackRedLight AuburnMedium AuburnDark AuburnOther if other, list: / --choose--Light BlondeMedium BlondeDark BlondeLight BrownMedium BrownDark BrownBlackRedLight AuburnMedium AuburnDark AuburnOther if other, list:
Eye color / --choose--Light BlueMedium BlueDark BlueLight GreenMedium GreenDark GreenLight BrownMedium BrownDark BrownHazelOther if other, list: / --choose--Light BlueMedium BlueDark BlueLight GreenMedium GreenDark GreenLight BrownMedium BrownDark BrownHazelOther if other, list:
Occupation
Your Living Siblings
Sex / Date of birth / Hair color / Eye color / Medical conditions / Occupation
--choose--FemaleMale / --choose--Light BlondeMedium BlondeDark BlondeLight BrownMedium BrownDark BrownBlackRedLight AuburnMedium AuburnDark AuburnOther
if other, list: / --choose--Light BlueMedium BlueDark BlueLight GreenMedium GreenDark GreenLight BrownMedium BrownDark BrownHazelOther
if other, list:
--choose--FemaleMale / --choose--Light BlondeMedium BlondeDark BlondeLight BrownMedium BrownDark BrownBlackRedLight AuburnMedium AuburnDark AuburnOther
if other, list: / --choose--Light BlueMedium BlueDark BlueLight GreenMedium GreenDark GreenLight BrownMedium BrownDark BrownHazelOther
if other, list:
--choose--FemaleMale / --choose--Light BlondeMedium BlondeDark BlondeLight BrownMedium BrownDark BrownBlackRedLight AuburnMedium AuburnDark AuburnOther
if other, list: / --choose--Light BlueMedium BlueDark BlueLight GreenMedium GreenDark GreenLight BrownMedium BrownDark BrownHazelOther
if other, list:
--choose--FemaleMale / --choose--Light BlondeMedium BlondeDark BlondeLight BrownMedium BrownDark BrownBlackRedLight AuburnMedium AuburnDark AuburnOther
if other, list: / --choose--Light BlueMedium BlueDark BlueLight GreenMedium GreenDark GreenLight BrownMedium BrownDark BrownHazelOther
if other, list:
--choose--FemaleMale / --choose--Light BlondeMedium BlondeDark BlondeLight BrownMedium BrownDark BrownBlackRedLight AuburnMedium AuburnDark AuburnOther
if other, list: / --choose--Light BlueMedium BlueDark BlueLight GreenMedium GreenDark GreenLight BrownMedium BrownDark BrownHazelOther
if other, list:
--choose--FemaleMale / --choose--Light BlondeMedium BlondeDark BlondeLight BrownMedium BrownDark BrownBlackRedLight AuburnMedium AuburnDark AuburnOther
if other, list: / --choose--Light BlueMedium BlueDark BlueLight GreenMedium GreenDark GreenLight BrownMedium BrownDark BrownHazelOther
if other, list:
UC Center for Reproductive Health
male Donor Form
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Last modified on: 9/11/2014, 11:36:54 AM
UC Health Center for Reproductive Health
Your Deceased SiblingsSex / Age at death / Hair color / Eye color / Medical conditions / Occupation while living
--choose--FemaleMale / --choose--Light BlondeMedium BlondeDark BlondeLight BrownMedium BrownDark BrownBlackRedLight AuburnMedium AuburnDark AuburnOther
if other, list: / --choose--Light BlueMedium BlueDark BlueLight GreenMedium GreenDark GreenLight BrownMedium BrownDark BrownHazelOther
if other, list:
--choose--FemaleMale / --choose--Light BlondeMedium BlondeDark BlondeLight BrownMedium BrownDark BrownBlackRedLight AuburnMedium AuburnDark AuburnOther
if other, list: / --choose--Light BlueMedium BlueDark BlueLight GreenMedium GreenDark GreenLight BrownMedium BrownDark BrownHazelOther
if other, list:
--choose--FemaleMale / --choose--Light BlondeMedium BlondeDark BlondeLight BrownMedium BrownDark BrownBlackRedLight AuburnMedium AuburnDark AuburnOther
if other, list: / --choose--Light BlueMedium BlueDark BlueLight GreenMedium GreenDark GreenLight BrownMedium BrownDark BrownHazelOther
if other, list:
Your Maternal Ancestry
grandMother / grandFather
Ethnicity/race / --choose--whiteblackHispanicAsianPacific IslanderAmerican IndianAlaskan Native --choose--AfricanArabic or PersianAustralianCanadianChineseDutch (Netherlands)EnglishFilipinoFrenchGermanIndian, NOT Native AmericanIrish/ScottishItalianJapaneseKoreanMexicanNative American IndianNorwegianRussian/Czech/SlovakianSpanish (Spain)SwedishSwissVietnameseDon't Know / --choose--whiteblackHispanicAsianPacific IslanderAmerican IndianAlaskan Native --choose--AfricanArabic or PersianAustralianCanadianChineseDutch (Netherlands)EnglishFilipinoFrenchGermanIndian, NOT Native AmericanIrish/ScottishItalianJapaneseKoreanMexicanNative American IndianNorwegianRussian/Czech/SlovakianSpanish (Spain)SwedishSwissVietnameseDon't Know
Date of birth
Medical conditions
Living? / --choose--YesNo if no, list cause: / --choose--YesNo if no, list cause:
Hair color / --choose--Light BlondeMedium BlondeDark BlondeLight BrownMedium BrownDark BrownBlackRedLight AuburnMedium AuburnDark AuburnOther if other, list: / --choose--Light BlondeMedium BlondeDark BlondeLight BrownMedium BrownDark BrownBlackRedLight AuburnMedium AuburnDark AuburnOther if other, list:
Eye color / --choose--Light BlueMedium BlueDark BlueLight GreenMedium GreenDark GreenLight BrownMedium BrownDark BrownHazelOther if other, list: / --choose--Light BlueMedium BlueDark BlueLight GreenMedium GreenDark GreenLight BrownMedium BrownDark BrownHazelOther if other, list:
Occupation
Your paternal Ancestry
grandMother / grandFather
Ethnicity/race / --choose--whiteblackHispanicAsianPacific IslanderAmerican IndianAlaskan Native --choose--AfricanArabic or PersianAustralianCanadianChineseDutch (Netherlands)EnglishFilipinoFrenchGermanIndian, NOT Native AmericanIrish/ScottishItalianJapaneseKoreanMexicanNative American IndianNorwegianRussian/Czech/SlovakianSpanish (Spain)SwedishSwissVietnameseDon't Know / --choose--whiteblackHispanicAsianPacific IslanderAmerican IndianAlaskan Native --choose--AfricanArabic or PersianAustralianCanadianChineseDutch (Netherlands)EnglishFilipinoFrenchGermanIndian, NOT Native AmericanIrish/ScottishItalianJapaneseKoreanMexicanNative American IndianNorwegianRussian/Czech/SlovakianSpanish (Spain)SwedishSwissVietnameseDon't Know
Date of birth
Medical conditions
Living? / --choose--YesNo if no, list cause: / --choose--YesNo if no, list cause:
Hair color / --choose--Light BlondeMedium BlondeDark BlondeLight BrownMedium BrownDark BrownBlackRedLight AuburnMedium AuburnDark AuburnOther if other, list: / --choose--Light BlondeMedium BlondeDark BlondeLight BrownMedium BrownDark BrownBlackRedLight AuburnMedium AuburnDark AuburnOther if other, list:
Eye color / --choose--Light BlueMedium BlueDark BlueLight GreenMedium GreenDark GreenLight BrownMedium BrownDark BrownHazelOther if other, list: / --choose--Light BlueMedium BlueDark BlueLight GreenMedium GreenDark GreenLight BrownMedium BrownDark BrownHazelOther if other, list:
Occupation
Inheritable disorders (including birth defects):
1st degree
Parents
Siblings
2nd degree
Cousins
Niece/nephew
Aunt/uncle
Grandparent
UC Center for Reproductive Health
male Donor Form
Page 7 of 7
Last modified on: 9/11/2014, 11:36:54 AM
UC Health Center for Reproductive Health
Has a family member been treated for the following:Alcoholism / --choose--yesno if yes, who: --choose--FatherMotherSisterBrotherPaternal GrandfatherPaternal GrandmotherMaternal GrandfatherMaternal GrandmotherOther if other, list
Alzheimer’s Disease / --choose--yesno if yes, who: --choose--FatherMotherSisterBrotherPaternal GrandfatherPaternal GrandmotherMaternal GrandfatherMaternal GrandmotherOther if other, list
Breast cancer / --choose--yesno if yes, who: --choose--FatherMotherSisterBrotherPaternal GrandfatherPaternal GrandmotherMaternal GrandfatherMaternal GrandmotherOther if other, list
Childhood blindness / --choose--yesno if yes, who: --choose--FatherMotherSisterBrotherPaternal GrandfatherPaternal GrandmotherMaternal GrandfatherMaternal GrandmotherOther if other, list
Childhood deafness / --choose--yesno if yes, who: --choose--FatherMotherSisterBrotherPaternal GrandfatherPaternal GrandmotherMaternal GrandfatherMaternal GrandmotherOther if other, list
Cleft lip/palate / --choose--yesno if yes, who: --choose--FatherMotherSisterBrotherPaternal GrandfatherPaternal GrandmotherMaternal GrandfatherMaternal GrandmotherOther if other, list
Colon cancer / --choose--yesno if yes, who: --choose--FatherMotherSisterBrotherPaternal GrandfatherPaternal GrandmotherMaternal GrandfatherMaternal GrandmotherOther if other, list
Color blindness / --choose--yesno if yes, who: --choose--FatherMotherSisterBrotherPaternal GrandfatherPaternal GrandmotherMaternal GrandfatherMaternal GrandmotherOther if other, list
Congenital heart disease / --choose--yesno if yes, who: --choose--FatherMotherSisterBrotherPaternal GrandfatherPaternal GrandmotherMaternal GrandfatherMaternal GrandmotherOther if other, list
Congenital hip dislocation / --choose--yesno if yes, who: --choose--FatherMotherSisterBrotherPaternal GrandfatherPaternal GrandmotherMaternal GrandfatherMaternal GrandmotherOther if other, list
Cruetzfeldt-Jacob disease / --choose--yesno if yes, who: --choose--FatherMotherSisterBrotherPaternal GrandfatherPaternal GrandmotherMaternal GrandfatherMaternal GrandmotherOther if other, list
Cystic Fibrosis / --choose--yesno if yes, who: --choose--FatherMotherSisterBrotherPaternal GrandfatherPaternal GrandmotherMaternal GrandfatherMaternal GrandmotherOther if other, list
Depression / --choose--yesno if yes, who: --choose--FatherMotherSisterBrotherPaternal GrandfatherPaternal GrandmotherMaternal GrandfatherMaternal GrandmotherOther if other, list
Down’s syndrome / --choose--yesno if yes, who: --choose--FatherMotherSisterBrotherPaternal GrandfatherPaternal GrandmotherMaternal GrandfatherMaternal GrandmotherOther if other, list
Dwarfism / --choose--yesno if yes, who: --choose--FatherMotherSisterBrotherPaternal GrandfatherPaternal GrandmotherMaternal GrandfatherMaternal GrandmotherOther if other, list
Dyslexia / --choose--yesno if yes, who: --choose--FatherMotherSisterBrotherPaternal GrandfatherPaternal GrandmotherMaternal GrandfatherMaternal GrandmotherOther if other, list
Early death (before age 35) / --choose--yesno if yes, who: --choose--FatherMotherSisterBrotherPaternal GrandfatherPaternal GrandmotherMaternal GrandfatherMaternal GrandmotherOther if other, list
Galactosemia / --choose--yesno if yes, who: --choose--FatherMotherSisterBrotherPaternal GrandfatherPaternal GrandmotherMaternal GrandfatherMaternal GrandmotherOther if other, list
High cholesterol requiring treatment / --choose--yesno if yes, who: --choose--FatherMotherSisterBrotherPaternal GrandfatherPaternal GrandmotherMaternal GrandfatherMaternal GrandmotherOther if other, list
Huntington’s Disease / --choose--yesno if yes, who: --choose--FatherMotherSisterBrotherPaternal GrandfatherPaternal GrandmotherMaternal GrandfatherMaternal GrandmotherOther if other, list
Hydrocephalus/spina bifida / --choose--yesno if yes, who: --choose--FatherMotherSisterBrotherPaternal GrandfatherPaternal GrandmotherMaternal GrandfatherMaternal GrandmotherOther if other, list
Juvenile onset diabetes / --choose--yesno if yes, who: --choose--FatherMotherSisterBrotherPaternal GrandfatherPaternal GrandmotherMaternal GrandfatherMaternal GrandmotherOther if other, list
Kidney disease (including dialysis) / --choose--yesno if yes, who: --choose--FatherMotherSisterBrotherPaternal GrandfatherPaternal GrandmotherMaternal GrandfatherMaternal GrandmotherOther if other, list
Learning disorders (ADHD, ADD, autism) / --choose--yesno if yes, who: --choose--FatherMotherSisterBrotherPaternal GrandfatherPaternal GrandmotherMaternal GrandfatherMaternal GrandmotherOther if other, list
Mania / --choose--yesno if yes, who: --choose--FatherMotherSisterBrotherPaternal GrandfatherPaternal GrandmotherMaternal GrandfatherMaternal GrandmotherOther if other, list
Mental retardation / --choose--yesno if yes, who: --choose--FatherMotherSisterBrotherPaternal GrandfatherPaternal GrandmotherMaternal GrandfatherMaternal GrandmotherOther if other, list
Multiple sclerosis / --choose--yesno if yes, who: --choose--FatherMotherSisterBrotherPaternal GrandfatherPaternal GrandmotherMaternal GrandfatherMaternal GrandmotherOther if other, list
Muscular dystrophy / --choose--yesno if yes, who: --choose--FatherMotherSisterBrotherPaternal GrandfatherPaternal GrandmotherMaternal GrandfatherMaternal GrandmotherOther if other, list
Ovarian cancer / --choose--yesno if yes, who: --choose--FatherMotherSisterBrotherPaternal GrandfatherPaternal GrandmotherMaternal GrandfatherMaternal GrandmotherOther if other, list
Phenylketonuria / --choose--yesno if yes, who: --choose--FatherMotherSisterBrotherPaternal GrandfatherPaternal GrandmotherMaternal GrandfatherMaternal GrandmotherOther if other, list
Premature heart attack (before age 50) / --choose--yesno if yes, who: --choose--FatherMotherSisterBrotherPaternal GrandfatherPaternal GrandmotherMaternal GrandfatherMaternal GrandmotherOther if other, list
Psychiatric problems / --choose--yesno if yes, who: --choose--FatherMotherSisterBrotherPaternal GrandfatherPaternal GrandmotherMaternal GrandfatherMaternal GrandmotherOther if other, list
Schizophrenia / --choose--yesno if yes, who: --choose--FatherMotherSisterBrotherPaternal GrandfatherPaternal GrandmotherMaternal GrandfatherMaternal GrandmotherOther if other, list
Sickle cell disease / --choose--yesno if yes, who: --choose--FatherMotherSisterBrotherPaternal GrandfatherPaternal GrandmotherMaternal GrandfatherMaternal GrandmotherOther if other, list
Sudden Infant Death / --choose--yesno if yes, who: --choose--FatherMotherSisterBrotherPaternal GrandfatherPaternal GrandmotherMaternal GrandfatherMaternal GrandmotherOther if other, list
Tay-Sachs Disease / --choose--yesno if yes, who: --choose--FatherMotherSisterBrotherPaternal GrandfatherPaternal GrandmotherMaternal GrandfatherMaternal GrandmotherOther if other, list
Thalassemia / --choose--yesno if yes, who: --choose--FatherMotherSisterBrotherPaternal GrandfatherPaternal GrandmotherMaternal GrandfatherMaternal GrandmotherOther if other, list
Thyroid disease / --choose--yesno if yes, who: --choose--FatherMotherSisterBrotherPaternal GrandfatherPaternal GrandmotherMaternal GrandfatherMaternal GrandmotherOther if other, list
For Doctor’s use only
UC Center for Reproductive Health
male Donor Form