AEVITAS SPERM BANK Aevitas Sperm Bank
Recommended number of straws to be used per procedure:
IUI 2 Straws
IVF 2 Straws
ICSI 1 Straw
The following information has been provided voluntarily and will be disclosed to future parents as
an aid in their selection.
GENERAL INFORMATION AND CHARACTERISTICS
PERSONAL DETAILS
PERSONALITY Describe yourself and personality:
Arranger, responsible, analytical and adaptable. Very humble, respectful and funny.
Describe any special skills, talents and abilities you have I believe I’m a good singer, I just need voice training.
What values are most important to you? Family and education.
Ethnic Origin: Xhosa
Race: Black
Height (m): 1.67
Weight (kg): 50
Shoe Size: 6
Blood Group: B+
Predominant Hand: Right
Occupation: Student
What are you studying?
Nursing (2 nd Year)
Religion: Christian
Marital Status: Single
Children: None
Are you adopted? No
I consider myself to
be humble, respectful
and funny
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DONOR PROFILE
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PHYSICAL ATTRIBUTES
Mouth Mouth Size Small Average Large
Lips Thin Average Full
Nose
Nose Size Small Medium Large
Nose Width Narrow Average Wide
Nose Length Short Average Long
Nose Bridge Concave Straight Convex
Eyes
Eye Colour Brown Green Blue Other:
Eyes Set Narrow Average Wide
Eye Size Small Average Large
Eye Sight Short Normal Far
Eyebrow Arc Flat Medium High
Eyebrow Thickness Thin Medium Thick
Hair & Ears
Hair colour at birth Black Brown Blonde Red
Hair colour as adult Black Brown Blonde Red
Hair texture Fine Medium Course
Hair fullness Thin Medium Thick Balding
Hair trait Straight Wavy Curly Very Curly
Ear size Small Average Large
Facial Features
Facial Freckles None Few Numerous
Dimples None Slight Medium Deep
Moles None One Several Numerous
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I received
recognition for
neatness, and
academics
I hope to study
medicine or do my
Masters in Trauma
and Emergency
Dental
Dental condition Poor Fair Excellent
Braces Yes No
Palette shape Narrow Average Wide Buck
EDUCATION School Matric Subjects:
isiXhosa, English, Life Orientation, Mathematics, Life Sciences, Physical Sciences and Geography
Favourite School Subjects: Geography and Life Sciences
Matric Aggregate Symbol: B
School Cultural Activities (Music/Art etc): Debate, athletics, music and peer education
School Sports:
Athletics
School Awards/Prizes:
Neatness, discipline and academics (isiXhosa and Geography)
Tertiary Education:
2nd year nursing at university
OtherQualifications: Computer course
Awards/Prizes: None
Future Educational Plans and Career Goals: Study Masters and specialise in Trauma and Emergency. Maybe study medicine later.
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LEISURE ACTIVITIES
Hobbies and/or interests since leaving school: None
Sports or outdoor activities: Currently not involved in any activities
Clubs or organisations: Member of Desmond Tutu LGBTI HIV foundation
MEDICAL HISTORY
Have you ever smoked for a prolonged period before?
No
Do you currently smoke? No
Do you drink alcohol and if so, how often?
Yes, occasionally, about once or twice monthly
Have you ever used any illicit drugs? Give details please.
Yes, marijuana
Please list any significant illnesses/operations you have had:
None
Please list any prescription drugs, complementary m edication or supplements you are currently taking and any medical conditions for which you are currently being seen/treated:
None
Have you ever had psychological or care? No
Have you ever had psychiatric care? No
How would you describe your health presently? Excellent
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FAMILY MEDICAL HISTORY
Are there any known genetic diseases or conditions that run in your family? No
Have you or anyone in your family ever been tested as a carrier for any genetic disease? (Give details if necessary)
No Are there any twins or triplets in your family? (Gi ve details, if ýes’)
No Is there anything else you would like to disclose a bout you and your family in regard to raising a child conceived with your sperm?
No
Family Profile
MOTHER FATHER SIBLING 1 SIBLING 2 SIBLING 3
Race Black Black x x x
Ethnic Ancestry Xhosa Xhosa x x x
Height (m) ≤1.6m ≤1.7m ≥1.67m ≥1.5m ≥1.2m
Weight (kg) 94kg 79kg 64kg 85kg 28kg
Eye Colour Brown Brown Brown Brown Brown
Natural Hair Colour Black Black Black Black Black
Natural Hair Type Very curly, Afro Very curly, Afro Very curly, Afro Very curly, Afro Very curly, Afro
Physical Build Full figure Slender Slender Full figure Thin
Special Skills, Talents and Abilities
Singing and very good in
maths
Plays soccer and regards self as a
good driver Modelling
Reading, computer skills
Plays soccer
General Health Has chronic illness
He’s in good health
Good Good Good
Personality
Very humble and caring and
puts others first. She is
quiet too
Shy and caring Reliable,
responsible, very humble
Sensitive loving and funny
Sensitive, humble and respectful
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Have you or any of your immediate family (parents, grandparents or siblings) ever had any of the following? (If yes, list the family memb er with the disorder):
NO YES MEMBER DETAILS
Alcoholism X Allergies X Alzheimer’sdisease X Anaemia X Arthritis X Asthma or other lung disorders X Cancer (type and age of onset) X Cardiovascular disease X Cerebralpalsy X Cystic fibrosis X Deafness X Depression X Diabetes X Mother Diagnosed with T1 in 2005 Disorder of eyes or eyesight X Drug abuse/ addiction X Emphysema X Endometriosis X Epilepsy X
Haemophilia (bleeding disorder) X Aunt Mom’s sister has Thrombocytopenia
High blood pressure X Mother Diagnosed in 2010 High cholesterol X Hyperactivity X Inherited metabolic disorders X Kidney disease X Learning disability X Leukaemia X Liver disease X Migraines X Multiple sclerosis X Muscular dystrophy X Osteoporosis X Ovarian cysts X Psychological disorders X Psychiatric disorders X Sickle cell anaemia X Skin disorders X Tay-Sach’s disease X Thalassemia X Thyroid disease X Tuberculosis X Grandmother Mom’s mother in 2005 Ulcers X
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QUESTIONS AND ANSWERS
Which celebrity(ies) do you think you look most sim ilar too?
Lunga Shabalala, Maps Maponyane, Blair Underwood
If you could meet anyone in the world (living or de ceased), who would it be and why?
Michael Jackson. I loved him since I was young.
If you had a free afternoon, what would you spend i t doing? Watching movies
If you could have one superpower, what would you be able to do?
Read people’s minds If you could do any activity, without having to wor ry about travel or money, what activity would it be?
Hiking
Which kind of charity would you choose to donate to if you had the means? A charity supporting homeless children
If you could pick any course at university, what wo uld it most likely be? Medicine
If you were reincarnated as an animal, which one wo uld it be?
Cat If you were on a survival course, what would be you r “I can’t live without it” item?
Cellphone
If you were about to walk the plank, what would you r last meal be?
Pasta with tuna and cheese sauce, mixed veg, chicken livers and green salad
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Aevitas Sperm Bank
REASONS FOR DONATING
Why do you want to become a donor? I believe I’m given to give. The feeling of knowing I helped making someone’s dream a reality is very satisfying.
What qualities do you think are important for paren ts to have? Have time for their children, provide safety and financial stability and a friend too.
If you could send a message to your prospective rec ipient, what would it be?
It is a great honour for me to be able to play a role in
giving you this precious gift of life. I hope that this will
bring you the world of joy and happiness. Please take
good care of this precious soul. May you be blessed in
abundance.