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Donor Selection Request
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BASIC AND BIOMETRIC INFORMATION
Height, cm: 165
Weight, kg: 67
Blood type and Rh factor: B (III) Rh+
Ethinicity: russian
Religion: caucasian
Character traits: sociable, kind, warm
Weight, kg: 67
Blood type and Rh factor: B (III) Rh+
Ethinicity: russian
Religion: caucasian
Character traits: sociable, kind, warm
Eye color: blue-gray
Eye shape: european
Nose: straight
Forehead: normal (straight)
Face: oval
Freckles/moles: yes
Eye shape: european
Nose: straight
Forehead: normal (straight)
Face: oval
Freckles/moles: yes
Hair type: wavy
Hair color: dirty-blonde
Grey hair: no
Constitution: mesomorphic (normal constitution)
Right-handed or left-handed: right-handed
Hair color: dirty-blonde
Grey hair: no
Constitution: mesomorphic (normal constitution)
Right-handed or left-handed: right-handed
LIFE STYLE
Marital status: married
Career field: housewife
Education: secondary vocational
Languages: russian
Career field: housewife
Education: secondary vocational
Languages: russian
Favorite sport: ice skating, dancing
Play musical instruments: yes
Hobbies, interests: music
Play musical instruments: yes
Hobbies, interests: music
Why did I become a donor?
I have become a donor because I believe that if a girl can’t get pregnant naturally, she needs help. Help in becoming a mother, experiencing that. I already have two children and am very happy. That’s the feeling I wanted to share with those girls.
Preferences
Favorite food: a little bit of everything
Favorite color: mint, turquoise, black
Favorite season: summer
Favorite holiday: New Year’s Eve and my birthday
Favorite color: mint, turquoise, black
Favorite season: summer
Favorite holiday: New Year’s Eve and my birthday
Favorite book: -
Favorite music genre: pop music
Favorite film: “Water for Elephants”, “Green Mile”, “Fantastic Beasts and Where to Find Them”
Pets: a cat
Favorite music genre: pop music
Favorite film: “Water for Elephants”, “Green Mile”, “Fantastic Beasts and Where to Find Them”
Pets: a cat
Information about children
Children: 2
Sex: boy and girl
Hearing/vision problems: yes (eye sight, but no glasses or lenses)
Mental health problems/autism: no
ADHD/hyperactivity: no
Sex: boy and girl
Hearing/vision problems: yes (eye sight, but no glasses or lenses)
Mental health problems/autism: no
ADHD/hyperactivity: no
Medical and genetic information
| Please assess your dental health by 5-grade scale | 3 of 5 |
| Have you ever worn braces? | Yes |
| Do you smoke? | Yes |
| Do you drink alcohol? How often? | Rarely |
| Do you have allergies? If you do, please, specify | No |
| Do you take prohibited substances? | No |
| Have you ever had blood transfusion? | No |
| Have you ever been hospitalized? | Yes |
| Does your family history have twins or triplets? | No |
| Do you have Ashkenazi Jews as your ancestors? | No |
| Do you have chronic diseases? If you do, please, specify | No |
| Do you take any medications? If you do, please, specify | No |
Have you or your blood relatives ever been diagnosed with any of the following diseases?
| Diseases | Donor | Father | Mother | Brothers | Sisters | Grandfather / On father's side | Grandfather / On mother's side | Grandmother / On father's side | Grandmother / On mother's side |
|---|---|---|---|---|---|---|---|---|---|
| Migraine | + | – | – | – | – | – | – | – | – |
| Mental disorders | – | – | – | – | – | – | – | – | – |
| Epilepsy | – | – | – | – | – | – | – | – | – |
| Muscular dystrophy | – | – | – | – | – | – | – | – | – |
| Hearing problems/deafness | – | – | – | – | – | – | – | – | – |
| Daltonism/blindness | – | – | – | – | – | – | – | – | – |
| Hyperopia/myopia | – | – | – | – | – | – | – | – | + |
| Glaucoma | – | – | – | – | – | – | – | – | + |
| Mental disorders | – | – | – | – | – | – | – | – | – |
| Frequent depression | – | – | – | – | – | – | – | – | – |
| Congenital disorders | – | – | – | – | – | – | – | – | – |
| Clubfoot | – | – | – | – | – | – | – | – | – |
| Dwarfism | – | – | – | – | – | – | – | – | – |
| Cardiovascular disease | – | – | – | – | – | – | – | – | – |
| More than two miscarriages | – | – | – | – | – | – | – | – | – |
| Skin pigmentation disorders - vitiligo | – | – | – | – | – | – | – | – | – |
| Psoriasis, neurodermatitis, skin hyperpigmentation | – | – | – | – | – | – | – | – | Psoriasis |
| Hair loss (age) | – | – | – | – | – | – | – | – | – |
| Oncological diseases (specify type) | – | – | – | – | – | – | – | – | – |
| Hemophilia | – | – | – | – | – | – | – | – | – |
| Heart attacks | – | – | – | – | – | – | – | – | – |
| Ulcer | – | – | – | – | – | – | – | – | + |
| Ovarian cyst | + | – | – | – | – | – | – | – | – |
| Ovarian tumors | – | – | – | – | – | – | – | – | – |
| Fibroma of the uterus | – | – | – | – | – | – | – | – | – |
| Uterine fibroids | – | – | – | – | – | – | – | – | – |
| Alcoholism | – | – | – | – | – | – | – | – | – |
| Drug addiction | – | – | – | – | – | – | – | – | – |
| Diabetes up to 55 years | – | – | – | – | – | – | – | – | – |
| Autism | – | – | – | – | – | – | – | – | – |
| Other | – | – | – | – | – | – | – | – | – |
