Questions
Personal Information
Talents:
| Voice: | Tenor |
| Instrument: Years of experience: | N/A |
| Other talents: Years of experience | N/A |
Favorite:
| Color | Green |
| Food | Fried chicken |
| Music | Classic country |
| Animal | Bear |
| Pet | Cat |
| Car | Toyota 4Runner |
| Movie | Braveheart |
| Song | Blue Eyes Crying in the Rain |
| Play | Midsummer Night’s Dream |
Goals:
| Academic | Maintain board certification |
| Professional | Clinical Director of Audiology |
| Personal | Summit Kilimanjaro |
Religion:
| Faith | Christian |
| Denomination | Non-denominational |
Languages:
| Speak | English |
| Read | English |
| Write | English |
Sports:
| Play | Rugby, American Football |
| Watch | All |
Siblings:
| # Brothers | 3 |
| # Sisters | 0 |
| 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 | 28 - 36 |
| GRE on scale of | 1090 - 1600 |
| 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 | 3.6 | 4 |
College
| Question | Response | on scale of |
| GPA on scale of | 3.3 | 4 |
Graduate School
| Question | Response | on scale of |
| GPA on scale of | 3.5 | 4 |
Subjects Studied:
| Major subjects | Communication Disorders |
| Minor subjects | American Sign Language |
Degrees
| Bachelor's | Communication Disorders |
| Master's | N/A |
| Doctorate | Audiology |
| Other(s) | N/A |
Awards & Activities
| High school | State Champion (rugby) |
| College | Collegiate All-American (rugby) |
| Academic | Honor Roll (high school, 4 years), Dean’s List (college, 10 semesters) |
| Professional | Board Certification (American Board of Audiology) |
| Political | N/A |
| Personal | N/A |
| Charitable | Special Olympics Healthy Hearing volunteer |
| 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) | 17 |
| Chest (inches) | 44 |
| Inseam (inches) | 34 |
| Waist (inches) | 34 |
| Sleeve (inches) | 35 |
| Wrist (inches) | 9 |
| Hat size | 7.38 |
| Shoe size | 13.5 |
Physical Aids
Eyes:
| Vision | Normal |
| Glasses | None |
| Astigmatism | No |
| Age started wearing glasses/contacts | N/A |
| Laser surgery? | No |
Dental:
| Device | Braces |
| Reason | Cosmetic |
| Age range during use | 10-12 |
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 | Social worker |
Donor's Father Education:
| Level | Graduate school |
| Degree | Master |
| Subject | Psychology |
Donor's Father Religion:
| Faith | Christian |
| Denomination | Catholic |
| Primary ethnic origins: | Irish, English |
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 | 71 |
| Height | 5’10” |
| Weight | 230 |
| Hands | Right-Handed |
Donor's Father Facial Features
Eyes:
| Eye Color | Brown |
| Eye shade | Medium |
| Vision | Near-Sighted |
| Glasses | Bifocal |
| Astigmatism | No |
| Age started wearing glasses/contacts yrs | 16 - 16 |
Hair:
| Original hair color | Brown |
| If gray, age turned gray | 55 |
| Type | Straight |
Skin:
| Skin Tone | MedL |
| Skin Condition | Medium |
Other:
| Chin cleft | Slight |
| Ear lobe | Detached |
| Facial Dimples | Slight |
Military
| Served in Military | No |
| Branch | N/A |
| Rank | N/A |
| Years of service | N/A |
Donor's Mother Personal Information
| Occupation | Social worker |
Donor's Mother Education:
| Level | Graduate school |
| Degree | Master |
| Subject | Psychology |
Donor's Mother Religion:
| Faith | Christian |
| Denomination | Non-denominational |
| Primary ethnic origins: | German, English |
Donor's Mother Languages:
| Speak | English |
| Read | English |
| Write | English |
Donor's Mother Talents:
| Voice | Tenor |
| Instrument yrs experience | N/A |
| Other yrs experience | N/A |
Donor's Mother Physical Information
Body
| Age | 65 |
| Height | 5’4” |
| Weight | 160 |
| Hands | Right-Handed |
Facial Features
Eyes:
| Eye Color | Blue |
| Eye shade | Medium |
| Vision | Near-Sighted |
| Glasses | Bifocal |
| Astigmatism | No |
| Age started wearing glasses/contacts yrs | 20 - 20 |
Hair:
| Original hair color | Brown |
| If gray, age turned gray | 50 |
| Type | Straight |
Skin:
| Skin Tone | Light |
| Skin Condition | Medium |
Other:
| Chin cleft | Slight |
| Ear lobe | Detached |
| 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 | 33 |
| Height | 5’11” |
| Weight | 205 |
| Hands | Right-Handed |
Sibling #1 Personal Information
| Occupation | Physician Assistant |
Education:
| Level | Graduate school |
| Degree | Other |
| Subject | Physician Assistant |
Religion:
| Faith | Christian |
| Denomination | Non-denominational |
Languages:
| Speak | English |
| Read | English |
| Write | English |
Talents:
| Voice | Tenor |
| Instrument Years of experience | N/A |
| Other Years of experience | N/A |
Sibling #1 Children:
| # Boys Ages: | 0 |
| # Girls Ages: | 1 - 1 |
Sibling #1 Facial Features
Eyes:
| Eye color | Brown |
| Eye shade | Medium |
| 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 | Curly |
Skin:
| Skin tone | Light |
| Skin condition | Medium |
Other:
| Chin cleft | Slight |
| Ear lobe | Detached |
| Facial dimples | Slight |
Military
| Served in military | No |
| Branch | N/A |
| Rank | N/A |
| Years of service | N/A |
Donor's Sibling #2
| Full/Half sibling | Half |
Sibling #2 Physical Information
Body
| Sex | Male |
| Age | 28 |
| Height | 5’9” |
| Weight | 165 |
| Hands | Right-Handed |
Sibling #2 Personal Information
| Occupation | Actuary |
Education:
| Level | College |
| Degree | Bachelor |
| Subject | Actuarial Science |
Religion:
| Faith | Christian |
| Denomination | Non-denominational |
Languages:
| Speak | English |
| Read | English |
| Write | English |
Talents:
| Voice | Tenor |
| Instrument Years of experience | Trombone - 4 |
| Other Years of experience | N/A |
Sibling #2 Children:
| # Boys Ages: | 0 |
| # Girls Ages: | 0 |
Sibling #2 Facial Features
Eyes:
| Eye color | Blue |
| Eye shade | Medium |
| Vision | Near-Sighted |
| Glasses | Bifocal |
| Astigmatism | No |
| Age started wearing glasses/contacts | 10 |
Hair:
| Original hair color | Brown |
| If gray, age turned gray | N/A |
| Type | Straight |
Skin:
| Skin tone | MedL |
| Skin condition | Oily |
Other:
| Chin cleft | Slight |
| Ear lobe | Detached |
| Facial dimples | Slight |
Military
| Served in military | No |
| Branch | N/A |
| Rank | N/A |
| Years of service | N/A |
Donor's Sibling #3
| Full/Half sibling | Half |
Sibling #3 Physical Information
Body
| Sex | Male |
| Age | 16 |
| Height | 5’9” |
| Weight | 150 |
| Hands | Right-Handed |
Sibling #3 Personal Information
| Occupation | None |
Education:
| Level | High school |
| Degree | Not Completed |
| Subject | General |
Religion:
| Faith | Christian |
| Denomination | Non-denominational |
Languages:
| Speak | English |
| Read | English |
| Write | English |
Talents:
| Voice | Tenor |
| Instrument Years of experience | N/A |
| Other Years of experience | N/A |
Sibling #3 Children:
| # Boys Ages: | 0 |
| # Girls Ages: | 0 |
Sibling #3 Facial Features
Eyes:
| Eye color | Blue |
| 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 | Medium |
Other:
| Chin cleft | Slight |
| Ear lobe | Detached |
| Facial dimples | Slight |
Military
| Served in military | No |
| Branch | N/A |
| Rank | N/A |
| Years of service | N/A |
Father's Siblings
Father's Brothers
| # of Brothers | 1 |
| Ages of Brothers: | 70 |
| Education levels for each: | Bachelors |
| Occupations for each: | Small Business Owner |
| Religions for each: | Catholic |
Father's Brothers' Total Children:
| # Boys | 2 |
| # Girls | N/A |
Father's Sisters
| # of Sisters | 1 |
| Ages of Sisters: | 69 |
| Education levels for each: | Bachelors |
| Occupations for each: | Accounting |
| Religions for each: | Catholic |
Father's Sisters' Total Children:
| # Boys | N/A |
| # Girls | N/A |
Mother's Siblings
Mother's Brothers
| # Brothers | 2 |
| Ages of Brothers: | 60, 59 |
| Education levels for each: | Bachelors, Bachelors |
| Occupations for each: | Engineering, Management |
| Religions for each: | Catholic (all) |
Mother's Brothers' Total Children:
| # Boys | 1 |
| # Girls | 2 |
Mother's Sisters
| # Sisters | 4 |
| Ages of Sisters: | 64, 62, 58, 55 |
| Education levels for each: | High School, High School, Bachelors, Bachelors |
| Occupations for each: | Insurance, Insurance, Sales, Management |
| Religions for each: | Catholic (all) |
Mother's Sisters' Total Children:
| # Boys | 1 |
| # Girls | 1 |
Father's Parents
Father's Father
Education
| Level | High school |
| Degree | Diploma |
| Subject | General |
| Occupation: | Business Owner |
| Primary ethnic origins: | Irish, English |
Siblings:
| # Brothers | 0 |
| # Sisters | 0 |
Other:
| Languages | English |
| Religion | Catholic |
Military
| Branch | Army |
| Rank | Military policeman |
| Service Yrs | 4 |
Father's Mother
Education
| Level | High school |
| Degree | Diploma |
| Subject | General |
| Occupation: | Business Owner |
| Primary ethnic origins: | English |
Siblings:
| # Brothers | 0 |
| # Sisters | 4 |
Other:
| Languages | English |
| Religion | Catholic |
Military
| Branch | N/A |
| Rank | N/A |
| Service Yrs | 0 |
Mother's Parents
Mother's Father
Education
| Level | College |
| Degree | Bachelor’s |
| Subject | Psychology |
| Occupation: | Detective, Head of Security |
| Primary ethnic origins: | German |
Siblings:
| # Brothers | 1 |
| # Sisters | 1 |
Other:
| Languages | English |
| Religion | Catholic |
Military
| Branch | Army |
| Rank | Bomber pilot |
| Service Yrs | 4 |
Mother's Mother
Education
| Level | High school |
| Degree | Diploma |
| Subject | General |
| Occupation: | Police officer |
| Primary ethnic origins: | English |
Siblings:
| # Brothers | 0 |
| # Sisters | 1 |
Other:
| Languages | English |
| Religion | Catholic |
Military
| Branch | N/A |
| Rank | N/A |
| Service Yrs | 0 |