  | Free Sperm Donor - Northern California / San Francisco Bay Area |
Medical History
Submitted by trent on Sun, 2010-08-29 22:48.
For the lifestyle questionnaire, see http://trentdonor.org/screening
For STD results, see http://trentdonor.org/std
Below is a questionnaire and information regarding Trent's medical history and can be reviewed by a recipient and their physician:
| Most Recent Physical Exam by an M.D. (Click below for copy) | Fitness Profile Page 1 (administered by an NASM Certified Personal Trainer) | Fitness Profile Page 2 (administered by an NASM Certified Personal Trainer) | Fitness Profile Page 3 (administered by an NASM Certified Personal Trainer) | Fitness Profile Page 4 (administered by an NASM Certified Personal Trainer) |
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Please list significant medical history since childhood:
| Age | Event |
| Age 5 | Chicken Pox (varicella-zoster virus) contracted with typical recovery. |
| Age 7 | 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 (genetic results coming soon) |
Are you aware of any of the following birth related conditions occuring with immediate family members:
| Trent's Answer | |
| _ YES √ NO | Stillbirth |
| _ YES √ NO | Miscarriage |
| _ 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 multiple sets of twins boys in Trent's extended family." |
Please list any additional known health conditions in immediate family members:
| Trent's Answers | |
| "history of high cholesterol on both the mother and father's side with onset in early 50's" | |
| "history of overweight status and obesity on both sides of family" | |
| "Mother is near-sighted" | |
| "Mother and sister take thyroid supplement for hypothyroidism" | |
| "Maternal grandfather survived a heart attack in his 50's" | |
| "Actinic keratoses removed from father in mid 60's from sun exposure" |