Ethnicity (check all that apply):
Highest % Ancestry Backgrounds of Great Grandparents outside US
(Okay to Guess):
Religion Born Into:
Education, Talent, Personality Background:
Have you ever been told you had any of the following issues?
(please check all that apply)
Health Issues Not Disclosed
I hereby certify that my answers and explanations, which were voluntarily given in this
questionnaire, are correct. I understand that the answers used in this questionnaire will
be used to determine my appropriateness as a donor and to help match me with a prospective
recipient. I will allow TED to share any of the information in this questionnaire with potential
recipient couples except my identifying information. I am not aware of any problems in myself,
my family, or my current or previous sexual partners that were not answered in the above questions.