SOME MORE INTERESTING FACTS ABOUT: YOUR STAR SIGN: WHAT DO YOU CONSIDER AS YOUR BEST FACIAL FEATURE: WHAT DO YOU CONSIDER TO BE YOUR BEST PHYSICAL FEATURE: HOW WOULD YOU DESCRIBE YOUR SMILE: HOW WOULD YOU DESCRIBE YOUR LAUGH: WHICH ACTRESS OR FAMOUS PERSON YOU THINK YOU RESEMBLE: Eve408 Gemini My Smile My Legs Friendly and approachable Loud! Fergie (Black Eyed Peas) FAVOURITES FOOD/S: Pizza & Sushi BOOK/S: White Oleander; Sandcastles MOVIE/S: Armageddon; We bought a Zoo; Burlesque; Dirty Dancing SONG/S: Wide Awake Katy Perry; Closer Kings of Leon YOU PLAY A MUSICAL INSTRUMENT? No MUSICAL INSTRUMENT: - ACTOR/ESS: George Cloony; Channing Tatum; Jennifer Aniston; Gerhard Butler COLOUR: Pink CAR: Maserati Grand Torino FLOWER: Deep Purple Rose GEM STONE: Clear Diamond ANIMAL: Dogs TIME OF DAY: Night SEASON: Summer DESTINATION: Greece HISTORICAL FIGURE: Grace Kelly PERSON YOU WOULD MOST LIKE TO MEET: President Jacob Zuma WHY? I would like to question him on 99, 9% of the decisions he makes on a daily basis, since I do not agree with any of them FAVOURITE SUBJECT @ SCHOOL: Accounting; Business Studies; Languages ANY SPECIAL AWARDS/ACHIEVMENTS: Youngest dance instructor FAVOURITE QUOTE: Do not go where the path may lead; rather go where there is no path and leave a trail PERSONAL PREFERENCES/ABILITIES ARE YOU SKILLED: HOW WOULD YOU RATE YOUR ABILITY IN MATH: LITERARY SKILLS: SCIENTIFIC/ RESEARCH ABILITIES: ARTISTIC TALENTS: MUSIC SKILLS / ABILITIES: ATHLETIC ABILITIES: HOW MANY LANGUAGES CAN YOU SPEAK: MECHANICALLY / TECHNICALLY 2 Afrikaans and English
SPECIAL SKILLS & PERSONALITY OF FAMILY MEMBERS Music/Artistic/Athletic/Scientific/Math skills/personality/employment/hobbies/other interesting facts MOTHER: My mother was an amazing swimmer. She stopped swimming just before she got her national swimming colours, due to pregnancy. My mother is the pure definition of loving, caring and friendly. She is a beautiful person, inside and out. She is considerate, outgoing and sensitive. Like me, she loves things to be clean and organized. She loves reading, exercising and interacting with people. She has an occasional urge to adopt a little animal, which she then does FATHER: My father is a strict and very intelligent man. In his matric year, he was head boy, and he was also a very good athlete. He just loves economics, in which he did his MBA, and now he is an Ophthalmic Dispenser. BROTHER/S: I am happy to say that my older brother got married a few weeks ago. He is a true sportsman. He plays golf, rugby and loves to swim. During his matric year, he received the award for Athlete of the Year. He is a funloving, people s person. My stepbrother I can only describe as the most loving boy ever. He loves playing guitar, practicing karate and of course, playing rugby. He loves the outdoors very much, but nothing can stop him from staying inside and watching a good movie. Someday he plans to go to the army to fight for his country. SISTER/S: My sister is simply gorgeous. She is, just like my brother, a people s person. She is very energetic and loves to hike. Then there is my stepsister too energetic. This includes building puzzles and playing mommy to her dolls. In between being quite busy, she loves to practice ballet. In my opinion she is very intelligent. HANDWRITING SAMPLE KEIRSEY TEMPERAMENT: GUARDIAN Guardians are the cornerstone of society, for they are the temperament given to serving and preserving our most important social institutions. Guardians have natural talent in managing goods and services--from supervision to maintenance and supply -- and they use all their skills to keep things running smoothly in their families, communities, schools, churches, hospitals, and businesses. All Guardians share the following core characteristics: Guardians pride themselves on being dependable, helpful, and hard-working. Guardians make loyal mates, responsible parents, and stabilizing leaders. Guardians tend to be dutiful, cautious, humble, and focused on credentials and traditions. Guardians are concerned citizens who trust authority, join groups, seek security, prize gratitude, and dream of meting out justice. Guardians can have a lot of fun with their friends, but they are quite serious about their duties and responsibilities. Guardians take pride in being dependable and trustworthy; if there's a job to be done, they can be counted on to put their shoulder to the wheel. Guardians also believe in law and order and sometimes worry that respect for authority even a fundamental sense of right and wrong, is being lost. Perhaps this is why Guardians honour customs and traditions so strongly -- they are familiar patterns that help bring stability to our modern, fast-paced world. Practical and down-to-earth, Guardians believe in following the rules and cooperating with others. They are not very comfortable winging it or blazing new trails; working steadily within the system is the Guardian way, for in the long run loyalty, discipline, and teamwork get the job done right. Guardians are meticulous about schedules and have a sharp eye for proper procedures. They ar e cautious about change, even though they know that change can be healthy for an institution. Better to go slowly, they say, and look before you leap. Guardians make up as much as 40 to 45 percent of the population, and a good thing, because they usually end up doing all the indispensable but thankless jobs the rest of the population takes for granted. Guardian Portraits: Mother Teresa, William Howard Taft, Harry S. Truman, George Washington
FACIAL CHARACTERISTICS Face Shape: Square Eye Shape: Hooded/ Down turned/ Almond/ Round/Protruding Eye Set: Narrow /Close /Average /Deep/ Wide Eye Size: Small / Average / Large Eye colour: Hazel Lip Shape: Full/ Thin / Flat upper Lip/ Perfect/ Large top lip/ Droopy shape Nose Shapes: Wavy / Snub / Flat / Aquiline / Upturned / Straight Hair Line: Straight / Round / Widow s Peak Hair form: Wavy /Curly /Straight / Ethnic Hair Texture: Average / Thick / Fine / Coarse / Thin Premature Graying: Yes / No, If yes, at what age: Hair Colour: Golden Brown Present hair loss: None /Thinning Complexion: Fair Tan Ability: None / Slight / Medium / Easy Cheek Bones: High /Low / Wide / Flat / Pointed Facial Features: Moles / Freckles / Dimples /Beauty Spots / Cleft Chin / Gap tooth / Overbite / None PHYSICAL CHARACTERISTICS Body Shape: Neat Hourglass Height: 1.70m Weight: 65Kg BMI: 22.4 Build: Petite/Small/Medium/Athletic/Large/Stocky Hands: Right-handed/ Left-handed /Ambidextrous
MEDICAL PROFILE PERSONAL HEALTH HISTORY Blood Group (ABO): O Rhesus: + Are you adopted? No Are either of your parents adopted? No Vision (without corrective lenses): Poor / Fair / Good / Excellent Do you wear corrective lenses? No If yes, for what problem(s)? Farsighted / Short-sighted /Other: Explain: N/A Hearing (without corrective aids): Poor / Fair / Good / Excellent Do you wear corrective aids? No/Yes If yes, for what problems? N/A Do you smoke cigarettes? No/Yes If yes, how many per day? Do you drink alcohol? No/Yes If yes, how often? Once a week Diet: Vegetarian / Non vegetarian / Other: Allergies: Yes/No If yes, are they to: Food(s) /Medication(s)/Cosmetics/Environmental /Animals / Insects For each allergy, describe specific substance and reaction(s) and age first noticed: Substance: Reaction(s): Age: Explain allergies you have outgrown: N/A Exercise/ Sporting activities: None / Occasional / Regular Type of Exercise: Spinning, Jogging, Gyming Have you had any surgery (ies)? No/Yes, If yes please explain: Removal of Wisdom Teeth Have you had any hospitalization(s) not mentioned above? No Have you had a blood transfusion? No Are you a blood donor? Yes Have you had major radiation or x-ray exposure? No If yes, explain: Have you had any psychological or psychiatric care? No If yes, explain: Are you currently taking any medications, prescribed or over the counter? Yes If yes, please list: Yasmin Are you currently using any recreational drugs? No If yes, please list:
Have you ever been excluded from blood donation for reason of infectious disease? Do you have any physical deformities for which you have sought surgical corrections? If so, please explain: Have you ever been tested as a carrier of? Tay-Sach s disease Sickle Cell disease Thalassemia Cystic Fibrosis Carrier Non-carrier Unknown FERTILITY HISTORY AFC: Measured AMH: Tested Have you ever been pregnant? No Do you have any children? No If yes, please complete below: Sex: Year of birth: Health Status: Any special comments concerning your children? Are you currently on any form of birth control? Yes, Do you have a regular period? Yes Is there any history of fertility problems in your family (difficulty conceiving or miscarriages)? No PSYCHOLOGICAL ASSESSMENT All our donors undergo psychological screening prior to their first donation. This assessment and subsequent assessments are valid for one year. If you would like more information on this donor s assessment; we will put you in touch with the psychologist responsible for the donor s evaluation. The clinic may require you to sign consent before you proceed with the donor. *Depression is present in one member of donor s family, and although this is not seen as an exclusion factor, you are required to give your consent in order to proceed with this donor. Clinic psychologist has given her professional opinion and advices that this donor is fit to donate.
Eye Colour Hair Colour Complexion Weight Height Build SEUAL HEALTH HISTORY Have you or any of your sexual partner been in contact with anyone or have personally been treated for any of the following: NO TO ALL Self Partner When HIV NSU (non specific urethritis) Syphilis Gonorrhea Chlamydia Venereal Warts Herpes Viral Hepatitis B or C Hemophilia Received human-derived clotting factor concentrates IV (intravenous) drug use Other sexually transmitted diseases Do you practice safe sex at all times? Yes Do you consider your sexual practices risky for HIV infection? No Have you or any of your sexual partners: -engaged in sexual relations with a partner of the same sex during the last 5 years? No -had sex in exchange for money or drugs in the preceding 5 years? No -within the past 12 months undergone tattooing, acupuncture, ear or body piercing? No FAMILY HEALTH HISTORY (Natural eye & hair colour; fair/light/medium/dark complexion; small/medium/large frame/build) Mother Dark Brown Dark brown Medium 49Kg +/- 1.65m Small Father Hazel Brown Fair 95Kg +/-1.9m Medium (Athletic) Brother (full) Brother(half) Sister (full) Sister (half) Dark Brown Blue Dark Brown Hazel Black Blond Dark brown Light brown Medium Fair 90Kg Still growing 45Kg Still growing +/-1.8m Still growing +/-1.66m Still growing Med/Athletic Child/ren - - - - - - Small MGM Brown Dark brown Medium +/-75Kg +/-1.65m Small MGF Blue Brown/Black Fair +/-95Kg +/-1.8m Medium (Athletic) PGM Brown Dark Brown Fair +/-80Kg +/-1.65m Medium PGF Blue Brown Fair +/-90Kg +/-1.88m Medium (MGM = Maternal Grandmother, MGF = Maternal Grandfather, PGM = Paternal Grandmother, PGF = Paternal Grandfather, - = Unknown)
How many full blood siblings are in your immediate family (including yourself)? 3 Number of Males: 1 Number of Females: 2 How many half siblings are in your immediate family? 5 If so, from which parent? Mother and Father Number of Males: 1 Number of Females: 1 How many adopted siblings are in your immediate family (including yourself)? None Number of Males: Number of Females: Are there any twins or triplets in your family? Yes If yes, what relations are they to you? Mother s Cousins Are there any known genetic diseases or conditions that run in your family? No If yes, please identify: Have you or any family members described above had genetic counseling? No If yes, please describe: Are there any members of your family with a history of learning disabilities? No If yes, please explain: List below the ages of the following biological members of your family; if they are deceased, please list cause of death. Year of Birth Age at time of death Cause of death Mother 1965 Father 1964 Half Brother 1982 2005 Sister(s) 1988 Half sister 2007 MGM 1941 +/-65 Heart Attack MGF 1942 +/-66 Liver Cancer PGM 1928 +/-78 Brain Cancer PGF 1936 +/-40 Cancer
Medical problems which are present in biological family members: You Mother Father Sibling MGM MGF PGM PGF HEART stroke heart attack heart disease or defect 1. from birth 2. other hardening of the arteries high blood pressure Hereditary high cholesterol high cholesterol level BLOOD anemia sickle-cell anemia Hemophilia/bleeding disorder HIV / AIDS Leukemia other blood disorder RESPIRATORY Asthma Lung cancer emphysema tuberculosis GASTRO-INTESTINAL ulcer of stomach/duodenum hepatitis (all types) cirrhosis other liver disease ulcerative colitis Crohn's disease cystic fibrosis Pyloric stenosis Multiple Polyposis of colon rectal disorder METABOLIC/ENDOCRINE diabetes (age of onset) thyroid Goiter hyperactivity Phenyl Ketonuria (PKU) dwarfism URINARY Kidney disease other disease/defect of urinary tract MGM: Stroke at age of +/-66 Heart Attack at age +/- 66 High Blood pressure since age 40
You Mother Father Sibling MGM MGF PGM PGF NEUROLOGICAL migraines Mental retardation Senility before age 50 Multiple Sclerosis Cerebral Palsy epilepsy/seizure Hydrocephalus Spina bifida neural tube defect Tuberous Sclerosis Parkinsonism Creutzfeldt-Jakob Disease scoliosis other diseases MENTAL HEALTH depression schizophrenia manic depressive/bipolar disorder MUSCLE/BONE/JOINTS muscular dystrophy other chronic muscle disease loss of muscle coordination Lupus/other auto immune diseases osteoporosis Marfan Syndrome Arthritis SIGHT/SOUND/SMELL deafness before age 60 deformity of the ear cataracts before age 50 blindness color blindness severe Myopia glaucoma Retinoblastoma Retinitis Pigmentosa other sight/sound/smell disorder SKIN Acne Albinism Eczema pigmentation disorders neurofibromatosis other disorders of the skin Down Syndrome Other (i.eturner, Fragile, etc CANCER Breast Ovarian Colon Skin Thyroid cervical Uterine Other x x x OTHER alcoholism drug abuse, misuse or addiction Father diagnosed with Depression after serving time in the army. He had a difficult time in the army. Circumstantial No other family members diagnosed with depression. No history in the family. PGF diagnosed with Cancer at age +/- 40. MGF diagnosed with Cancer at age +/-66. Doctors said it was as a result of stress. PGM diagnosed with Cancer at age 87. PGM she passed away soon after it was diagnosed, as it had already spread.