Donor Number 441

General Information

Donor Code:
441
Ethnic Origin:
Chinese, Dutch, English, Filipino, German, Hawaiian, Irish, Korean, Portuguese
Blood Type:
O Positive
Hair Color:
Brown
Type of Hair:
Wavy
Thickness of Hair:
Thick
Age at Time of Retrieval:
26-27
Eye Color:
Brown
Complexion Relative to Race:
Medium
Bone Structure:
Medium
Height:
5'6"
Weight:
145
Handedness:
Right-Handed

Being a mother, hiking and fishing, crafts, and action movies.

Education Status: Undergraduate Student

Area of Study: Nursing

Vision: Good, does not wear lenses

Hearing: Excellent

Dentition: Good, no orthodontia required

Allergies: Ibuprofen

Hospitalization: 2000's, 2010's, 2010's, 2010's

Alcohol Usage: Does not drink alcohol

Tobacco Usage: Does not smoke

Drug Usage: Tests NEGATIVE for Drugs of Abuse.

Paternal Grandfather: Died in his 60's, Heart attack in his 60s

Paternal Grandmother: Alive and in her 60's, Healthy

Maternal Grandfather: Alive and in his 80's, Healthy

Maternal Grandmother: Alive and in her 70's, Heart attack in her 60's, stroke in her 60's

Father: Alive and in his 40's, Healthy

Mother: Alive and in her 40's, Healthy, asthma triggered by irritants

Siblings: At least one sibling, all in good health

Genetic Screening Performed: Yes

This donor has been screened for 107 genetic diseases (via targeted mutation analysis) and is not a carrier for any of the disease-causing mutations tested.

Genetic screening can reduce the risk for specific conditions tested but does not eliminate the risk for these conditions or for other untested conditions. There is a 3 to 4% chance that any child could be born with a birth defect, regardless of whether the child is conceived naturally or through assisted reproductive technologies. It is not possible to eliminate these risks or test for all of them before becoming pregnant.

ORIGINAL FAMILY HEALTH HISTORY:

The donor's personal and family health history was originally reported on 9/16/2015.

UPDATED HEALTH HISTORY:

No new information reported at this time.

Donor Communication (Type): Open

Limited Available?

Past Pregnancy: Yes

Face: Oval, average sized, average forehead set, few freckles, one dimple on left side when smiling, no cleft in chin

Lips: Upper and lower lips are full

Nose: Round shape, straight profile, slightly wide, average length, average nostril flare

Ears: Medium size, attached lobes, average distance from face

Eyes: Almond shape, medium size, average width apart, long lashes

Eyebrows: Medium thickness, angled

Summary: She has a very charming personality and a great sense of humor. She has beautiful golden skin and long thick hair. She is a strong, compassionate woman who values family above all else. She has a warm heart and is always patient and understanding.

 

Childhood Photos

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Medical History

Medical History: Birth Defects/Congenital Problems

Have you or any member of your family (by blood), had a problem or defect at birth of any of the following body systems?

Relative Problem at birth:
Bones, muscles, joints, limbs
Problem at birth:
Gastrointestinal system
Problem at birth:
Nervous system, brain, spinal cord
Problem at birth:
Blood circulatory system
Self
Mother
Father
Brother 1:
Sister 1:
Sister 2:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Maternal Uncle 1:
Maternal Uncle 2:
Paternal Uncle 1:
Paternal Uncle 2:
Maternal Cousin 1:
Maternal Cousin 2:
Maternal Cousin 3:
Maternal Cousin 4:
Maternal Cousin 5:
Maternal Cousin 6:
Paternal Cousin 1:
Paternal Cousin 2:

Medical History: Birth Defects/Congenital Problems (cont.)

Have you or any member of your family (by blood), had a problem or defect at birth of any of the following body systems?

Relative Problem at birth:
Breathing, respiratory system
Problem at birth:
Heart
Problem at birth:
Other organs
Problem at birth:
Genital, urinary, reproductive
Self
Mother
Father
Brother 1: born a month premature, had to have help breathing for a couple hours.
Sister 1:
Sister 2:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Maternal Uncle 1:
Maternal Uncle 2:
Paternal Uncle 1:
Paternal Uncle 2:
Maternal Cousin 1:
Maternal Cousin 2:
Maternal Cousin 3:
Maternal Cousin 4:
Maternal Cousin 5:
Maternal Cousin 6:
Paternal Cousin 1:
Paternal Cousin 2:

Medical History: Birth Defects/Congenital Problems (cont.)

Have you or any member of your family (by blood), had a problem or defect at birth of any of the following body systems?

Relative Problem at birth:
Metabolic
Problem at birth:
Learning disabilities
Problem at birth:
Other
Self
Mother
Father
Brother 1:
Sister 1:
Sister 2:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Maternal Uncle 1:
Maternal Uncle 2:
Paternal Uncle 1:
Paternal Uncle 2:
Maternal Cousin 1:
Maternal Cousin 2:
Maternal Cousin 3:
Maternal Cousin 4:
Maternal Cousin 5:
Maternal Cousin 6:
Paternal Cousin 1:
Paternal Cousin 2:

Medical History: Heart/Vascular

Relative Heart Attack
(age of onset)
Heart Disease
(age of onset)
High Blood Pressure
(age of onset)
Arrhythmia
(age of onset)
Self
Mother
Father
Brother 1:
Sister 1:
Sister 2:
Maternal Grandmother 60's 60's
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather 60's
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Maternal Uncle 1:
Maternal Uncle 2:
Paternal Uncle 1:
Paternal Uncle 2:
Maternal Cousin 1:
Maternal Cousin 2:
Maternal Cousin 3:
Maternal Cousin 4:
Maternal Cousin 5:
Maternal Cousin 6:
Paternal Cousin 1:
Paternal Cousin 2:

Medical History: Heart/Vascular (cont.)

Relative Stroke
(age of onset)
TIA (Mini Stroke)
(age of onset)
Aneurism
(age of onset)
Other Heart/Vascular Disorder
(age of onset & disorder)
Self
Mother
Father
Brother 1:
Sister 1:
Sister 2:
Maternal Grandmother 60's
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Maternal Uncle 1:
Maternal Uncle 2:
Paternal Uncle 1:
Paternal Uncle 2:
Maternal Cousin 1:
Maternal Cousin 2:
Maternal Cousin 3:
Maternal Cousin 4:
Maternal Cousin 5:
Maternal Cousin 6:
Paternal Cousin 1:
Paternal Cousin 2:

Medical History: Blood

Relative Anemia
(age of onset)
Sickle Cell
(age of onset)
Hemophilia
(age of onset)
Leukemia
(age of onset)
Self 20's
Mother
Father
Brother 1:
Sister 1:
Sister 2:
Maternal Grandmother 60's
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Maternal Uncle 1:
Maternal Uncle 2:
Paternal Uncle 1:
Paternal Uncle 2:
Maternal Cousin 1:
Maternal Cousin 2:
Maternal Cousin 3:
Maternal Cousin 4:
Maternal Cousin 5:
Maternal Cousin 6:
Paternal Cousin 1:
Paternal Cousin 2:

Medical History: Blood (cont.)

Relative Immune Problems
(age of onset)
Other Blood Disorder
(age of onset & disorder)
Self
Mother
Father
Brother 1:
Sister 1:
Sister 2:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Maternal Uncle 1:
Maternal Uncle 2:
Paternal Uncle 1:
Paternal Uncle 2:
Maternal Cousin 1:
Maternal Cousin 2:
Maternal Cousin 3:
Maternal Cousin 4:
Maternal Cousin 5:
Maternal Cousin 6:
Paternal Cousin 1:
Paternal Cousin 2:

Medical History: Respiratory

Relative Hay Fever
(age of onset)
Asthma
(age of onset)
Emphysema
(age of onset)
Tuberculosis
(age of onset)
Self
Mother 30's
Father
Brother 1:
Sister 1:
Sister 2:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Maternal Uncle 1:
Maternal Uncle 2:
Paternal Uncle 1:
Paternal Uncle 2:
Maternal Cousin 1:
Maternal Cousin 2:
Maternal Cousin 3:
Maternal Cousin 4:
Maternal Cousin 5:
Maternal Cousin 6:
Paternal Cousin 1:
Paternal Cousin 2:

Medical History: Respiratory (cont.)

Relative Lung Cancer
(age of onset)
Pneumonia
(age of onset)
Other Respiratory Disorder
(age of onset & disorder)
Self
Mother
Father
Brother 1:
Sister 1:
Sister 2:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Maternal Uncle 1:
Maternal Uncle 2:
Paternal Uncle 1:
Paternal Uncle 2:
Maternal Cousin 1:
Maternal Cousin 2:
Maternal Cousin 3:
Maternal Cousin 4:
Maternal Cousin 5:
Maternal Cousin 6:
Paternal Cousin 1:
Paternal Cousin 2:

Medical History: Gastro-Intestinal

Relative Ulcers
(age of onset)
Gall Stones
(age of onset)
Hepatitis A
(age of onset)
Hepatitis B
(age of onset)
Self
Mother
Father
Brother 1:
Sister 1:
Sister 2:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Maternal Uncle 1:
Maternal Uncle 2:
Paternal Uncle 1:
Paternal Uncle 2:
Maternal Cousin 1:
Maternal Cousin 2:
Maternal Cousin 3:
Maternal Cousin 4:
Maternal Cousin 5:
Maternal Cousin 6:
Paternal Cousin 1:
Paternal Cousin 2:

Medical History: Gastro-Intestinal (cont.)

Relative Other Liver Disease
(age of onset)
Colon Cancer
(age of onset)
Ulcerative Colitis
(age of onset)
Crohn's Disease
(age of onset)
Self
Mother
Father
Brother 1:
Sister 1:
Sister 2:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Maternal Uncle 1:
Maternal Uncle 2:
Paternal Uncle 1:
Paternal Uncle 2:
Maternal Cousin 1:
Maternal Cousin 2:
Maternal Cousin 3:
Maternal Cousin 4:
Maternal Cousin 5:
Maternal Cousin 6:
Paternal Cousin 1:
Paternal Cousin 2:

Medical History: Gastro-Intestinal (cont.)

Relative Cystic Fibrosis
(age of onset)
Intestinal Cancer
(age of onset)
Other Gastro-Intestinal Disorder
(age of onset & disorder)
Self
Mother
Father
Brother 1:
Sister 1:
Sister 2:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Maternal Uncle 1:
Maternal Uncle 2:
Paternal Uncle 1:
Paternal Uncle 2:
Maternal Cousin 1:
Maternal Cousin 2:
Maternal Cousin 3:
Maternal Cousin 4:
Maternal Cousin 5:
Maternal Cousin 6:
Paternal Cousin 1:
Paternal Cousin 2:

Medical History: Metabolic/Endocrine

Relative Diabetes
(age of onset)
Hypoglycemia
(age of onset)
Thyroid Cancer
(age of onset)
Thyroid Disease
(age of onset)
Self
Mother
Father
Brother 1:
Sister 1:
Sister 2:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Maternal Uncle 1:
Maternal Uncle 2:
Paternal Uncle 1:
Paternal Uncle 2:
Maternal Cousin 1:
Maternal Cousin 2:
Maternal Cousin 3:
Maternal Cousin 4:
Maternal Cousin 5:
Maternal Cousin 6:
Paternal Cousin 1:
Paternal Cousin 2:

Medical History: Metabolic/Endocrine (cont.)

Relative Goiter
(age of onset)
Adrenal Disorder
(age of onset)
Hyperactivity
(age of onset)
Other Metabolic/Endocrine Disorder
(age of onset & disorder)
Self
Mother
Father
Brother 1:
Sister 1:
Sister 2:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Maternal Uncle 1:
Maternal Uncle 2:
Paternal Uncle 1:
Paternal Uncle 2:
Maternal Cousin 1:
Maternal Cousin 2:
Maternal Cousin 3:
Maternal Cousin 4:
Maternal Cousin 5:
Maternal Cousin 6:
Paternal Cousin 1:
Paternal Cousin 2:

Medical History: Urinary

Relative Kidney Disease
(age of onset)
Disease of Ureter, Bladder, Urethra
(age of onset)
Rectal Disorder
(age of onset)
Other Urinary Disorder
(age of onset & disorder)
Self
Mother
Father
Brother 1:
Sister 1:
Sister 2:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Maternal Uncle 1:
Maternal Uncle 2:
Paternal Uncle 1:
Paternal Uncle 2:
Maternal Cousin 1:
Maternal Cousin 2:
Maternal Cousin 3:
Maternal Cousin 4:
Maternal Cousin 5:
Maternal Cousin 6:
Paternal Cousin 1:
Paternal Cousin 2:

Medical History: Genital/Reproductive

Relative Undescended Testicle(s)
(age of onset)
Hypospadiasis
(age of onset)
HPV/Genital Warts
(age of onset)
Genital Herpes
(age of onset)
Self
Mother
Father
Brother 1:
Sister 1:
Sister 2:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Maternal Uncle 1:
Maternal Uncle 2:
Paternal Uncle 1:
Paternal Uncle 2:
Maternal Cousin 1:
Maternal Cousin 2:
Maternal Cousin 3:
Maternal Cousin 4:
Maternal Cousin 5:
Maternal Cousin 6:
Paternal Cousin 1:
Paternal Cousin 2:

Medical History: Genital/Reproductive (cont.)

Relative Prostate Cancer
(age of onset)
Uterine Fibroids
(age of onset)
Ovarian Cysts
(age of onset)
Cancer of the Cervix
(age of onset)
Self
Mother
Father
Brother 1:
Sister 1: 20's
Sister 2:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Maternal Uncle 1:
Maternal Uncle 2:
Paternal Uncle 1:
Paternal Uncle 2:
Maternal Cousin 1:
Maternal Cousin 2:
Maternal Cousin 3:
Maternal Cousin 4:
Maternal Cousin 5:
Maternal Cousin 6:
Paternal Cousin 1:
Paternal Cousin 2:

Medical History: Genital/Reproductive (cont.)

Relative Cancer of the Uterus
(age of onset)
Varicocele Other Genital/Reproductive Disorder
(age of onset & disorder)
Self
Mother
Father
Brother 1:
Sister 1:
Sister 2:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Maternal Uncle 1:
Maternal Uncle 2:
Paternal Uncle 1:
Paternal Uncle 2:
Maternal Cousin 1:
Maternal Cousin 2:
Maternal Cousin 3:
Maternal Cousin 4:
Maternal Cousin 5:
Maternal Cousin 6:
Paternal Cousin 1:
Paternal Cousin 2:

Medical History: Skin

Relative Acne
(age of onset)
Scarring Acne
(age of onset)
Eczema
(age of onset)
Psoriasis
(age of onset)
Self Teens Teens
Mother
Father
Brother 1: Teens
Sister 1: Teens
Sister 2: Teens
Maternal Grandmother 60's
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3: 30's
Maternal Uncle 1:
Maternal Uncle 2:
Paternal Uncle 1:
Paternal Uncle 2:
Maternal Cousin 1: Teens
Maternal Cousin 2:
Maternal Cousin 3:
Maternal Cousin 4:
Maternal Cousin 5: Pre-Teens
Maternal Cousin 6:
Paternal Cousin 1:
Paternal Cousin 2:

Medical History: Skin (cont.)

Relative Skin Cancer
(age of onset)
Pigmentation Disorders
(age of onset)
Other Skin Disorder
(age of onset & disorder)
Self
Mother
Father
Brother 1:
Sister 1:
Sister 2:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Maternal Uncle 1:
Maternal Uncle 2:
Paternal Uncle 1:
Paternal Uncle 2:
Maternal Cousin 1:
Maternal Cousin 2:
Maternal Cousin 3:
Maternal Cousin 4:
Maternal Cousin 5:
Maternal Cousin 6:
Paternal Cousin 1:
Paternal Cousin 2:

Medical History: Neurological

Relative Migraines
(age of onset)
Mental Retardation
(age of onset)
Alzheimers
(age of onset)
Multiple Sclerosis
(age of onset)
Self
Mother
Father
Brother 1:
Sister 1:
Sister 2:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Maternal Uncle 1:
Maternal Uncle 2:
Paternal Uncle 1:
Paternal Uncle 2:
Maternal Cousin 1:
Maternal Cousin 2:
Maternal Cousin 3:
Maternal Cousin 4:
Maternal Cousin 5:
Maternal Cousin 6:
Paternal Cousin 1:
Paternal Cousin 2:

Medical History: Neurological (cont.)

Relative Cerebral Palsey
(age of onset)
Epilepsy
(age of onset)
Hydrocephalus
(age of onset)
Spinal Cord Disorder
(age of onset)
Self
Mother
Father
Brother 1:
Sister 1:
Sister 2:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Maternal Uncle 1:
Maternal Uncle 2:
Paternal Uncle 1:
Paternal Uncle 2:
Maternal Cousin 1:
Maternal Cousin 2:
Maternal Cousin 3:
Maternal Cousin 4:
Maternal Cousin 5:
Maternal Cousin 6:
Paternal Cousin 1:
Paternal Cousin 2:

Medical History: Neurological (cont.)

Relative Huntington's Chorea
(age of onset)
Gaucher's Disease
(age of onset)
Wilson's Disease
(age of onset)
Other Neurological Disorder
(age of onset & disorder)
Self
Mother
Father
Brother 1:
Sister 1:
Sister 2:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Maternal Uncle 1:
Maternal Uncle 2:
Paternal Uncle 1:
Paternal Uncle 2:
Maternal Cousin 1:
Maternal Cousin 2:
Maternal Cousin 3:
Maternal Cousin 4:
Maternal Cousin 5:
Maternal Cousin 6:
Paternal Cousin 1:
Paternal Cousin 2:

Medical History: Mental Health

Relative Schizophrenia
(age of onset)
Manic Depression
(age of onset)
Clinical Depression
(age of onset)
Other Mental Health Disorder
(age of onset & disorder)
Self
Mother
Father
Brother 1:
Sister 1:
Sister 2:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Maternal Uncle 1:
Maternal Uncle 2:
Paternal Uncle 1:
Paternal Uncle 2:
Maternal Cousin 1:
Maternal Cousin 2:
Maternal Cousin 3:
Maternal Cousin 4:
Maternal Cousin 5:
Maternal Cousin 6:
Paternal Cousin 1:
Paternal Cousin 2:

Medical History: Muscles/Bones/Joints

Relative Muscular Dystrophy
(age of onset)
Other Chronic Muscle Disease
(age of onset & disorder)
Lupus
(age of onset)
Deformity of Spine
(age of onset)
Self
Mother
Father
Brother 1:
Sister 1:
Sister 2:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Maternal Uncle 1:
Maternal Uncle 2:
Paternal Uncle 1:
Paternal Uncle 2:
Maternal Cousin 1:
Maternal Cousin 2:
Maternal Cousin 3:
Maternal Cousin 4:
Maternal Cousin 5:
Maternal Cousin 6:
Paternal Cousin 1:
Paternal Cousin 2:

Medical History: Muscles/Bones/Joints (cont.)

Relative Osteoporosis
(age of onset)
Dwarfism
(age of onset)
Arthritis
(age of onset)
Gout
(age of onset)
Self
Mother
Father
Brother 1:
Sister 1:
Sister 2:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Maternal Uncle 1:
Maternal Uncle 2:
Paternal Uncle 1:
Paternal Uncle 2:
Maternal Cousin 1:
Maternal Cousin 2:
Maternal Cousin 3:
Maternal Cousin 4:
Maternal Cousin 5:
Maternal Cousin 6:
Paternal Cousin 1:
Paternal Cousin 2:

Medical History: Muscles/Bones/Joints (cont.)

Relative Myasthenia Gravis
(age of onset)
Other Muscle/Bone/Joint Disorder
(age of onset & disorder)
Self
Mother
Father
Brother 1:
Sister 1:
Sister 2:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Maternal Uncle 1:
Maternal Uncle 2:
Paternal Uncle 1:
Paternal Uncle 2:
Maternal Cousin 1:
Maternal Cousin 2:
Maternal Cousin 3:
Maternal Cousin 4:
Maternal Cousin 5:
Maternal Cousin 6:
Paternal Cousin 1:
Paternal Cousin 2:

Medical History: Sight/Hearing/Olfactory

Relative Deafness before age 60
(age of onset)
Deformity of the Ear
(age of onset)
Cataracts before age 50
(age of onset)
Blindness
(age of onset)
Self
Mother
Father
Brother 1:
Sister 1:
Sister 2:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Maternal Uncle 1:
Maternal Uncle 2:
Paternal Uncle 1:
Paternal Uncle 2:
Maternal Cousin 1:
Maternal Cousin 2:
Maternal Cousin 3:
Maternal Cousin 4:
Maternal Cousin 5:
Maternal Cousin 6:
Paternal Cousin 1:
Paternal Cousin 2:

Medical History: Sight/Hearing/Olfactory (cont.)

Relative Color Blindness
(age of onset)
Glaucoma
(age of onset)
Deviated Septum
(age of onset)
Sinusitis
(age of onset)
Self
Mother
Father
Brother 1:
Sister 1:
Sister 2:
Maternal Grandmother 60's
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Maternal Uncle 1:
Maternal Uncle 2:
Paternal Uncle 1:
Paternal Uncle 2:
Maternal Cousin 1:
Maternal Cousin 2:
Maternal Cousin 3:
Maternal Cousin 4:
Maternal Cousin 5:
Maternal Cousin 6:
Paternal Cousin 1:
Paternal Cousin 2:

Medical History: Sight/Hearing/Olfactory (cont.)

Relative Other Sight/Hearing/Olfactory Disorder
(age of onset & disorder)
Self
Mother
Father
Brother 1:
Sister 1:
Sister 2:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Maternal Uncle 1:
Maternal Uncle 2:
Paternal Uncle 1:
Paternal Uncle 2:
Maternal Cousin 1:
Maternal Cousin 2:
Maternal Cousin 3:
Maternal Cousin 4:
Maternal Cousin 5:
Maternal Cousin 6:
Paternal Cousin 1:
Paternal Cousin 2:

Medical History: Other

Relative Alcoholism
(age of onset)
Drug Abuse or Addiction
(age of onset)
Smoker/Tobacco Use
(age of onset)
Self
Mother
Father 30's 30's 20's
Brother 1:
Sister 1:
Sister 2:
Maternal Grandmother
Maternal Grandfather 20's
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Maternal Uncle 1:
Maternal Uncle 2:
Paternal Uncle 1:
Paternal Uncle 2:
Maternal Cousin 1:
Maternal Cousin 2:
Maternal Cousin 3:
Maternal Cousin 4:
Maternal Cousin 5:
Maternal Cousin 6:
Paternal Cousin 1:
Paternal Cousin 2:

Medical History: Other (cont.)

Relative Oral Herpes/Cold Sores
(age of onset)
Other Disorder
(age of onset & disorder)
Breast Cancer
(age of onset)
Any Other Cancer
(age of onset & disorder)
Self
Mother
Father
Brother 1:
Sister 1:
Sister 2: Pre-Teens
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Maternal Uncle 1:
Maternal Uncle 2:
Paternal Uncle 1:
Paternal Uncle 2:
Maternal Cousin 1:
Maternal Cousin 2:
Maternal Cousin 3:
Maternal Cousin 4:
Maternal Cousin 5:
Maternal Cousin 6:
Paternal Cousin 1:
Paternal Cousin 2: