Questions
Personal Information
Talents:
| Voice: | Alto |
| Instrument: Years of experience: | Drums - 2 |
| Other talents: Years of experience | Painting - 7 |
Favorite:
| Color | Blue |
| Food | Sushi |
| Music | Hip hop |
| Animal | Cheetah |
| Pet | Fish |
| Car | Lamborghini |
| Movie | Blood Diamond |
| Song | Victory |
| Play | Les Miserables |
Goals:
| Academic | Completed my acedemic goals |
| Professional | More satisfying job |
| Personal | Long term relationship |
Religion:
| Faith | None |
| Denomination | N/A |
Languages:
| Speak | English |
| Read | English |
| Write | English |
Sports:
| Play | Soccer, Frisbee, Tennis, Basketball, |
| Watch | None preferred over others |
Siblings:
| # Brothers | 1 |
| # Sisters | 2 |
| Are you a twin? Identical or fraternal? | No |
| # of twins in your family | 0 |
| # Identical sets | 0 |
| # Fraternal sets | 0 |
Academics
Standard Test Score: provide score or denote N/A if not taken
| SAT on scale of | N/A |
| ACT on scale of | 30 - out of 36 |
| GRE on scale of | N/A |
| MCAT on scale of | N/A |
| LSAT on scale of | N/A |
| GMAT on scale of | N/A |
| TOEFL on scale of | N/A |
| Other on scale of | N/A |
High School
| Question | Response | on scale of |
| GPA on scale of | 3.5 | 4 |
College
| Question | Response | on scale of |
| GPA on scale of | 3.2 | 4 |
Graduate School
| Question | Response | on scale of |
| GPA on scale of | 3.2 | 4 |
Subjects Studied:
| Major subjects | Pharmacy |
| Minor subjects | Chemistry |
Degrees
| Bachelor's | N/A |
| Master's | N/A |
| Doctorate | PharmD |
| Other(s) | N/A |
Awards & Activities
| High school | N/A |
| College | N/A |
| Academic | N/A |
| Professional | Preceptor of the year at Pharmacy School |
| Political | N/A |
| Personal | Hiking, Biking, Painting, Team sports, Art museums |
| Charitable | N/A |
| Others | N/A |
Military
| Served in military | No |
| Branch | N/A |
| Rank | N/A |
| Years of service | N/A |
Physical Features
| Hands | Right-Handed |
| Fingers | Long |
Sizes & Measurements
| Neck (inches) | 13 |
| Chest (inches) | 37.5 |
| Inseam (inches) | 30 |
| Waist (inches) | 29 |
| Sleeve (inches) | 30 |
| Wrist (inches) | 30 |
| Hat size | 7 |
| Shoe size | 11 |
Physical Aids
Eyes:
| Vision | Normal |
| Glasses | None |
| Astigmatism | No |
| Age started wearing glasses/contacts | N/A |
| Laser surgery? | No |
Dental:
| Device | None |
| Reason | N/A |
| Age range during use | N/A |
Other Physical Aids:
| List | N/A |
| Reason/cause | N/A |
Facial Features
Eyes:
| Set |
|
| Size |
|
| Shape |
|
| Color |
|
| Shade |
|
Narrow
Average
Wide
Small
Average
Large
Almond
Oval
RoundEyebrows:
| Arch |
|
| Thickness |
|
| Set |
|
Thin
Average
ThickNose:
| Size |
|
| Shape |
|
| Width |
|
| Length |
|
| Bridge |
|
| Nostril flare |
|
| Septum |
|
Round
Straight
Wide
Convex
Straight
ConcaveCheekbones:
| Set |
|
| Prominence |
|
Mouth:
| Size |
|
| Lips |
|
| Turn |
|
Small
Average
Large
Thin
Average
FullTeeth:
| Size |
|
| Set |
|
| Condition |
|
Average
Large
SmallChin:
| Shape |
|
| Prominence |
|
| Cleft |
|
Round
Oval
Square
None
Slight
StrongEars:
| Size |
|
| Set |
|
| Angle |
|
| Lobe size |
|
| Lobe attachment |
|
Small
Average
Large
Flat
Average
Acute
Detached
AttachedHair:
| Color at birth |
|
| Natural color in adulthood |
|
| Shade |
|
| Type |
|
| Fullness |
|
| Texture |
|
Skin:
| Tone |
|
| Tan ability |
|
| Condition |
|
Hairline:
| Forehead |
|
| Contour |
|
Other Facial Features:
| Moles |
|
| Freckles |
|
| Dimples |
|
| Adam's apple |
|
Facial Hair
| Thickness |
|
| Shade |
|
Family Information
Donor's Parents
Donor's Father Personal Information
| Occupation | Physician |
Donor's Father Education:
| Level | Graduate school |
| Degree | Doctorate |
| Subject | Internal Medicine |
Donor's Father Religion:
| Faith | Christian |
| Denomination | Lutheran |
| Primary ethnic origins: | German |
Donor's Father Languages:
| Speak | English |
| Read | English |
| Write | English |
Donor's Father Talents:
| Voice | Tenor |
| Instrument yrs experience | N/A |
| Other yrs experience | N/A |
Donor's Father Physical Information
Body
| Age | 63 |
| Height | 6' |
| Weight | 195 |
| Hands | Right-Handed |
Donor's Father Facial Features
Eyes:
| Eye Color | Brown |
| Eye shade | Medium |
| Vision | Far-Sighted |
| Glasses | Single |
| Astigmatism | No |
| Age started wearing glasses/contacts yrs | 15 |
Hair:
| Original hair color | Brown |
| If gray, age turned gray | 50 |
| Type | Wavy |
Skin:
| Skin Tone | Med |
| Skin Condition | Medium |
Other:
| Chin cleft | None |
| Ear lobe | Detached |
| Facial Dimples | None |
Military
| Served in Military | No |
| Branch | N/A |
| Rank | N/A |
| Years of service | N/A |
Donor's Mother Personal Information
| Occupation | Homemaker |
Donor's Mother Education:
| Level | College |
| Degree | Bachelor |
| Subject | Nursing |
Donor's Mother Religion:
| Faith | Christian |
| Denomination | Lutheran |
| Primary ethnic origins: | German |
Donor's Mother Languages:
| Speak | English |
| Read | English |
| Write | English |
Donor's Mother Talents:
| Voice | Soprano |
| Instrument yrs experience | Piano - 5 |
| Other yrs experience | N/A |
Donor's Mother Physical Information
Body
| Age | 63 |
| Height | 5'5" |
| Weight | 195 |
| Hands | Right-Handed |
Facial Features
Eyes:
| Eye Color | Blue |
| Eye shade | Light |
| Vision | Near-Sighted |
| Glasses | Single |
| Astigmatism | No |
| Age started wearing glasses/contacts yrs | 25 |
Hair:
| Original hair color | Blond |
| If gray, age turned gray | 50 |
| Type | Curly |
Skin:
| Skin Tone | Light |
| Skin Condition | Medium |
Other:
| Chin cleft | Slight |
| Ear lobe | Attached |
| Facial Dimples | Slight |
Military
| Served in Military | No |
| Branch | N/A |
| Rank | N/A |
| Years of service | N/A |
Donor's Siblings
Donor's Sibling(s) (1-4)
Donor's Sibling #1
| Full/Half sibling | Full |
Sibling #1 Physical Information
Body
| Sex | Male |
| Age | 35 |
| Height | 6'2" |
| Weight | 180 |
| Hands | Right-Handed |
Sibling #1 Personal Information
| Occupation | Physician |
Education:
| Level | Graduate school |
| Degree | Doctorate |
| Subject | Medicine |
Religion:
| Faith | Christian |
| Denomination | Lutheran |
Languages:
| Speak | English |
| Read | English |
| Write | English |
Talents:
| Voice | Baritone |
| Instrument Years of experience | Guitar - 7 |
| Other Years of experience | N/A |
Sibling #1 Children:
| # Boys Ages: | 0 |
| # Girls Ages: | 1 - age 2 |
Sibling #1 Facial Features
Eyes:
| Eye color | Blue |
| Eye shade | Medium |
| Vision | Far-Sighted |
| Glasses | Single |
| Astigmatism | No |
| Age started wearing glasses/contacts | 18 |
Hair:
| Original hair color | Brown |
| If gray, age turned gray | N/A |
| Type | Wavy |
Skin:
| Skin tone | Med |
| Skin condition | Medium |
Other:
| Chin cleft | Medium |
| Ear lobe | Attached |
| Facial dimples | None |
Military
| Served in military | No |
| Branch | N/A |
| Rank | N/A |
| Years of service | N/A |
Donor's Sibling #2
| Full/Half sibling | Full |
Sibling #2 Physical Information
Body
| Sex | Female |
| Age | 29 |
| Height | 5'9" |
| Weight | 160 |
| Hands | Right-Handed |
Sibling #2 Personal Information
| Occupation | Homemaker |
Education:
| Level | College |
| Degree | Bachelor |
| Subject | Education |
Religion:
| Faith | Christian |
| Denomination | Lutheran |
Languages:
| Speak | English |
| Read | English |
| Write | English |
Talents:
| Voice | Soprano |
| Instrument Years of experience | N/A |
| Other Years of experience | N/A |
Sibling #2 Children:
| # Boys Ages: | 0 |
| # Girls Ages: | 2 - ages 3, and 6 months |
Sibling #2 Facial Features
Eyes:
| Eye color | Green |
| Eye shade | Light |
| Vision | Normal |
| Glasses | None |
| Astigmatism | No |
| Age started wearing glasses/contacts | N/A |
Hair:
| Original hair color | Brown |
| If gray, age turned gray | N/A |
| Type | Straight |
Skin:
| Skin tone | Light |
| Skin condition | Dry |
Other:
| Chin cleft | None |
| Ear lobe | Detached |
| Facial dimples | None |
Military
| Served in military | No |
| Branch | N/A |
| Rank | N/A |
| Years of service | N/A |
Donor's Sibling #3
| Full/Half sibling | Full |
Sibling #3 Physical Information
Body
| Sex | Female |
| Age | 25 |
| Height | 5'10" |
| Weight | 160 |
| Hands | Right-Handed |
Sibling #3 Personal Information
| Occupation | Homemaker |
Education:
| Level | Some college |
| Degree | Associate |
| Subject | Biology |
Religion:
| Faith | Christian |
| Denomination | Lutheran |
Languages:
| Speak | English |
| Read | English |
| Write | English |
Talents:
| Voice | Alto |
| Instrument Years of experience | N/A |
| Other Years of experience | N/A |
Sibling #3 Children:
| # Boys Ages: | 1 - age 2 |
| # Girls Ages: | 0 |
Sibling #3 Facial Features
Eyes:
| Eye color | Blue |
| Eye shade | Medium |
| Vision | Far-Sighted |
| Glasses | None |
| Astigmatism | No |
| Age started wearing glasses/contacts | N/A |
Hair:
| Original hair color | Auburn |
| If gray, age turned gray | N/A |
| Type | Straight |
Skin:
| Skin tone | Med |
| Skin condition | Oily |
Other:
| Chin cleft | None |
| Ear lobe | Detached |
| Facial dimples | None |
Military
| Served in military | No |
| Branch | N/A |
| Rank | N/A |
| Years of service | N/A |
Father's Siblings
Father's Brothers
| # of Brothers | 2 |
| Ages of Brothers: | 60, 58 |
| Education levels for each: | Masters, High school |
| Occupations for each: | Pharmacist, Business owner |
| Religions for each: | Lutheran, Lutheran |
Father's Brothers' Total Children:
| # Boys | N/A |
| # Girls | N/A |
Father's Sisters
| # of Sisters | 1 |
| Ages of Sisters: | 61 |
| Education levels for each: | RN |
| Occupations for each: | Nurse |
| Religions for each: | Lutheran |
Father's Sisters' Total Children:
| # Boys | 1 |
| # Girls | N/A |
Mother's Siblings
Mother's Brothers
| # Brothers | 1 |
| Ages of Brothers: | 58 |
| Education levels for each: | College |
| Occupations for each: | Engineer |
| Religions for each: | Lutheran |
Mother's Brothers' Total Children:
| # Boys | 1 |
| # Girls | 3 |
Mother's Sisters
| # Sisters | 2 |
| Ages of Sisters: | 0 (deceased), 64 |
| Education levels for each: | none, College |
| Occupations for each: | none, Barber |
| Religions for each: | none, Lutheran |
Mother's Sisters' Total Children:
| # Boys | 4 |
| # Girls | 2 |
Father's Parents
Father's Father
Education
| Level | High School |
| Degree | Diploma |
| Subject | N/A |
| Occupation: | Salesman |
| Primary ethnic origins: | German |
Siblings:
| # Brothers | 0 |
| # Sisters | 1 |
Other:
| Languages | English |
| Religion | Lutheran |
Military
| Branch | Air Force |
| Rank | Navigator, unknown rank |
| Service Yrs | 3 |
Father's Mother
Education
| Level | College |
| Degree | RN |
| Subject | Nursing |
| Occupation: | Homemaker |
| Primary ethnic origins: | German |
Siblings:
| # Brothers | 0 |
| # Sisters | 1 |
Other:
| Languages | English |
| Religion | Lutheran |
Military
| Branch | N/A |
| Rank | N/A |
| Service Yrs | 0 |
Mother's Parents
Mother's Father
Education
| Level | High School |
| Degree | Diploma |
| Subject | N/A |
| Occupation: | Business Owner |
| Primary ethnic origins: | German |
Siblings:
| # Brothers | 4 |
| # Sisters | 4 |
Other:
| Languages | English |
| Religion | Lutheran |
Military
| Branch | Unknown |
| Rank | Unknown |
| Service Yrs | 2 |
Mother's Mother
Education
| Level | High School |
| Degree | Diploma |
| Subject | N/A |
| Occupation: | Homemaker |
| Primary ethnic origins: | German |
Siblings:
| # Brothers | 2 |
| # Sisters | 3 |
Other:
| Languages | English |
| Religion | Lutheran |
Military
| Branch | N/A |
| Rank | N/A |
| Service Yrs | 0 |