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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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.