Donor Number 672

General Information

Donor Code:
672
Ethnic Origin:
American Indian, English, French, German, Swedish, Swiss, Yugoslavian
Blood Type:
B Positive
Hair Color:
Light Brown
Type of Hair:
Straight
Thickness of Hair:
Average
Age at Time of Retrieval:
26-27
Eye Color:
Hazel
Complexion Relative to Race:
Fair
Bone Structure:
Small
Height:
5'5"
Weight:
130
Handedness:
Right-Handed

She loves to be active and play sports, especially volleyball. She also loves to bake and spend time with her family and friends. She is always up for learning new things and being adventurous.

Education Status: High School Diploma Obtained

Area of Study: Medical Laboratory Science

Vision: Excellent, does not wear lenses

Hearing: Excellent

Dentition: Fair, orthodontia required

Allergies: None known

Hospitalization: None known

Alcohol Usage: Does not drink alcohol

Tobacco Usage: Does not smoke

Drug Usage: Tests NEGATIVE for Drugs of Abuse.

Paternal Grandfather: Died in his 80's, Decline in health due to Alzheimers

Paternal Grandmother: Died in her 80's, Heart Attack in her 80's

Maternal Grandfather: Died in his 80's, Lung cancer in his 50's, skin cancer in his 60s; smoker

Maternal Grandmother: Alive and in her 80's, Rheumatoid Arthritis in her 60's, Osteoporosis in her 80's, COPD in her 80s, smoker

Father: Alive and in his 50's, Healthy

Mother: Alive and in her 50's, Healthy

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 has been found to test positive for the following:

MTHFR Deficiency

All people carry mutations for genetic disorders. Genetic testing can identify some of those mutations. We perform testing for a large number of conditions that are inherited in a recessive manner to help detect some of the mutations in our donors. Since all people carry mutations, donors are not excluded from our program when these mutations are identified. The donors' offspring are not at risk to develop the condition unless the other biological parent also carrier a mutation for the same inherited disorder. We encourage you to use the results of the donor's testing and consider your own genetic testing to help identify a donor suitable for your needs.

ORIGINAL FAMILY HEALTH HISTORY:

The donor's personal and family health history was originally reported on 4/2/2015.

UPDATED HEALTH HISTORY:

No new information reported at this time.

Donor Communication (Type): Open

Limited Available? No

Past Pregnancy: Yes

Face: Heart shaped, average forehead set, few freckles across bridge of nose.

Lips: Thin upper lip and medium fullness to lower lip.

Nose: Straight nose, rounded tip in side view, average size

Ears: Attached lobes, average size.

Eyes: Medium size, almond shape with long lashes

Eyebrows: Thin fullness, curved shape

Summary: She is so sweet and caring. She is enthusiastic about life, has a great smile, and beautiful eyes!

 

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
Sister 1:
Sister 2:
Sister 3:
Sister 4:
Sister 5:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Maternal Aunt 4:
Maternal Uncle 1:
Maternal Uncle 2:
Paternal Aunt 1:
Paternal Aunt 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:
Maternal Cousin 7:
Maternal Cousin 8:
Maternal Cousin 9:
Maternal Cousin 10:
Maternal Cousin 11:
Maternal Cousin 12:
Maternal Cousin 13:
Maternal Cousin 14:
Maternal Cousin 15:
Maternal Cousin 16:
Maternal Cousin 17:
Maternal Cousin 18:
Paternal Cousin 1:
Paternal Cousin 2:
Paternal Cousin 3:
Paternal Cousin 4:
Paternal Cousin 5:
Paternal Cousin 6:

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
Sister 1:
Sister 2:
Sister 3:
Sister 4:
Sister 5:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Maternal Aunt 4:
Maternal Uncle 1:
Maternal Uncle 2:
Paternal Aunt 1:
Paternal Aunt 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:
Maternal Cousin 7:
Maternal Cousin 8:
Maternal Cousin 9:
Maternal Cousin 10:
Maternal Cousin 11:
Maternal Cousin 12:
Maternal Cousin 13:
Maternal Cousin 14:
Maternal Cousin 15:
Maternal Cousin 16:
Maternal Cousin 17:
Maternal Cousin 18:
Paternal Cousin 1:
Paternal Cousin 2:
Paternal Cousin 3:
Paternal Cousin 4:
Paternal Cousin 5:
Paternal Cousin 6:

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
Sister 1:
Sister 2:
Sister 3:
Sister 4:
Sister 5:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Maternal Aunt 4:
Maternal Uncle 1:
Maternal Uncle 2:
Paternal Aunt 1:
Paternal Aunt 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:
Maternal Cousin 7:
Maternal Cousin 8:
Maternal Cousin 9:
Maternal Cousin 10:
Maternal Cousin 11:
Maternal Cousin 12:
Maternal Cousin 13:
Maternal Cousin 14:
Maternal Cousin 15:
Maternal Cousin 16:
Maternal Cousin 17:
Maternal Cousin 18:
Paternal Cousin 1:
Paternal Cousin 2:
Paternal Cousin 3:
Paternal Cousin 4:
Paternal Cousin 5:
Paternal Cousin 6:

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
Sister 1:
Sister 2:
Sister 3:
Sister 4:
Sister 5:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother 80's
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Maternal Aunt 4:
Maternal Uncle 1:
Maternal Uncle 2:
Paternal Aunt 1:
Paternal Aunt 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:
Maternal Cousin 7:
Maternal Cousin 8:
Maternal Cousin 9:
Maternal Cousin 10:
Maternal Cousin 11:
Maternal Cousin 12:
Maternal Cousin 13:
Maternal Cousin 14:
Maternal Cousin 15:
Maternal Cousin 16:
Maternal Cousin 17:
Maternal Cousin 18:
Paternal Cousin 1:
Paternal Cousin 2:
Paternal Cousin 3:
Paternal Cousin 4:
Paternal Cousin 5:
Paternal Cousin 6:

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
Sister 1:
Sister 2:
Sister 3:
Sister 4:
Sister 5:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Maternal Aunt 4:
Maternal Uncle 1:
Maternal Uncle 2:
Paternal Aunt 1:
Paternal Aunt 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:
Maternal Cousin 7:
Maternal Cousin 8:
Maternal Cousin 9:
Maternal Cousin 10:
Maternal Cousin 11:
Maternal Cousin 12:
Maternal Cousin 13:
Maternal Cousin 14:
Maternal Cousin 15:
Maternal Cousin 16:
Maternal Cousin 17:
Maternal Cousin 18:
Paternal Cousin 1:
Paternal Cousin 2:
Paternal Cousin 3:
Paternal Cousin 4:
Paternal Cousin 5:
Paternal Cousin 6:

Medical History: Blood

Relative Anemia
(age of onset)
Sickle Cell
(age of onset)
Hemophilia
(age of onset)
Leukemia
(age of onset)
Self
Mother
Father
Sister 1:
Sister 2:
Sister 3:
Sister 4:
Sister 5:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Maternal Aunt 4:
Maternal Uncle 1:
Maternal Uncle 2:
Paternal Aunt 1:
Paternal Aunt 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:
Maternal Cousin 7:
Maternal Cousin 8:
Maternal Cousin 9:
Maternal Cousin 10:
Maternal Cousin 11:
Maternal Cousin 12:
Maternal Cousin 13:
Maternal Cousin 14:
Maternal Cousin 15:
Maternal Cousin 16:
Maternal Cousin 17:
Maternal Cousin 18:
Paternal Cousin 1:
Paternal Cousin 2:
Paternal Cousin 3:
Paternal Cousin 4:
Paternal Cousin 5:
Paternal Cousin 6:

Medical History: Blood (cont.)

Relative Immune Problems
(age of onset)
Other Blood Disorder
(age of onset & disorder)
Self
Mother
Father
Sister 1:
Sister 2:
Sister 3:
Sister 4:
Sister 5:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Maternal Aunt 4:
Maternal Uncle 1:
Maternal Uncle 2:
Paternal Aunt 1:
Paternal Aunt 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:
Maternal Cousin 7:
Maternal Cousin 8:
Maternal Cousin 9:
Maternal Cousin 10:
Maternal Cousin 11:
Maternal Cousin 12:
Maternal Cousin 13:
Maternal Cousin 14:
Maternal Cousin 15:
Maternal Cousin 16:
Maternal Cousin 17:
Maternal Cousin 18:
Paternal Cousin 1:
Paternal Cousin 2:
Paternal Cousin 3:
Paternal Cousin 4:
Paternal Cousin 5:
Paternal Cousin 6:

Medical History: Respiratory

Relative Hay Fever
(age of onset)
Asthma
(age of onset)
Emphysema
(age of onset)
Tuberculosis
(age of onset)
Self
Mother
Father
Sister 1:
Sister 2:
Sister 3:
Sister 4:
Sister 5:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Maternal Aunt 4:
Maternal Uncle 1:
Maternal Uncle 2:
Paternal Aunt 1:
Paternal Aunt 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:
Maternal Cousin 7:
Maternal Cousin 8:
Maternal Cousin 9:
Maternal Cousin 10:
Maternal Cousin 11:
Maternal Cousin 12:
Maternal Cousin 13:
Maternal Cousin 14:
Maternal Cousin 15:
Maternal Cousin 16:
Maternal Cousin 17:
Maternal Cousin 18:
Paternal Cousin 1:
Paternal Cousin 2:
Paternal Cousin 3:
Paternal Cousin 4:
Paternal Cousin 5:
Paternal Cousin 6:

Medical History: Respiratory (cont.)

Relative Lung Cancer
(age of onset)
Pneumonia
(age of onset)
Other Respiratory Disorder
(age of onset & disorder)
Self
Mother
Father
Sister 1:
Sister 2:
Sister 3:
Sister 4:
Sister 5:
Maternal Grandmother 80's COPD
Maternal Grandfather 50's
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Maternal Aunt 4:
Maternal Uncle 1:
Maternal Uncle 2:
Paternal Aunt 1:
Paternal Aunt 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:
Maternal Cousin 7:
Maternal Cousin 8:
Maternal Cousin 9:
Maternal Cousin 10:
Maternal Cousin 11:
Maternal Cousin 12:
Maternal Cousin 13:
Maternal Cousin 14:
Maternal Cousin 15:
Maternal Cousin 16:
Maternal Cousin 17:
Maternal Cousin 18:
Paternal Cousin 1:
Paternal Cousin 2:
Paternal Cousin 3:
Paternal Cousin 4:
Paternal Cousin 5:
Paternal Cousin 6:

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
Sister 1:
Sister 2:
Sister 3:
Sister 4:
Sister 5:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Maternal Aunt 4:
Maternal Uncle 1:
Maternal Uncle 2:
Paternal Aunt 1:
Paternal Aunt 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:
Maternal Cousin 7:
Maternal Cousin 8:
Maternal Cousin 9:
Maternal Cousin 10:
Maternal Cousin 11:
Maternal Cousin 12:
Maternal Cousin 13:
Maternal Cousin 14:
Maternal Cousin 15:
Maternal Cousin 16:
Maternal Cousin 17:
Maternal Cousin 18:
Paternal Cousin 1:
Paternal Cousin 2:
Paternal Cousin 3:
Paternal Cousin 4:
Paternal Cousin 5:
Paternal Cousin 6:

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
Sister 1:
Sister 2:
Sister 3:
Sister 4:
Sister 5:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Maternal Aunt 4:
Maternal Uncle 1:
Maternal Uncle 2:
Paternal Aunt 1:
Paternal Aunt 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:
Maternal Cousin 7:
Maternal Cousin 8:
Maternal Cousin 9:
Maternal Cousin 10:
Maternal Cousin 11:
Maternal Cousin 12:
Maternal Cousin 13:
Maternal Cousin 14:
Maternal Cousin 15:
Maternal Cousin 16:
Maternal Cousin 17:
Maternal Cousin 18:
Paternal Cousin 1:
Paternal Cousin 2:
Paternal Cousin 3:
Paternal Cousin 4:
Paternal Cousin 5:
Paternal Cousin 6:

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
Sister 1:
Sister 2:
Sister 3:
Sister 4:
Sister 5:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Maternal Aunt 4:
Maternal Uncle 1:
Maternal Uncle 2:
Paternal Aunt 1:
Paternal Aunt 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:
Maternal Cousin 7:
Maternal Cousin 8:
Maternal Cousin 9:
Maternal Cousin 10:
Maternal Cousin 11:
Maternal Cousin 12:
Maternal Cousin 13:
Maternal Cousin 14:
Maternal Cousin 15:
Maternal Cousin 16:
Maternal Cousin 17:
Maternal Cousin 18:
Paternal Cousin 1:
Paternal Cousin 2:
Paternal Cousin 3:
Paternal Cousin 4:
Paternal Cousin 5:
Paternal Cousin 6:

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
Sister 1:
Sister 2:
Sister 3:
Sister 4:
Sister 5:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Maternal Aunt 4:
Maternal Uncle 1:
Maternal Uncle 2:
Paternal Aunt 1:
Paternal Aunt 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:
Maternal Cousin 7:
Maternal Cousin 8:
Maternal Cousin 9:
Maternal Cousin 10:
Maternal Cousin 11:
Maternal Cousin 12:
Maternal Cousin 13:
Maternal Cousin 14:
Maternal Cousin 15:
Maternal Cousin 16:
Maternal Cousin 17:
Maternal Cousin 18:
Paternal Cousin 1:
Paternal Cousin 2:
Paternal Cousin 3:
Paternal Cousin 4:
Paternal Cousin 5:
Paternal Cousin 6:

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
Sister 1:
Sister 2:
Sister 3:
Sister 4:
Sister 5:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Maternal Aunt 4:
Maternal Uncle 1:
Maternal Uncle 2:
Paternal Aunt 1:
Paternal Aunt 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:
Maternal Cousin 7:
Maternal Cousin 8:
Maternal Cousin 9:
Maternal Cousin 10:
Maternal Cousin 11:
Maternal Cousin 12:
Maternal Cousin 13:
Maternal Cousin 14:
Maternal Cousin 15:
Maternal Cousin 16:
Maternal Cousin 17:
Maternal Cousin 18:
Paternal Cousin 1:
Paternal Cousin 2:
Paternal Cousin 3:
Paternal Cousin 4:
Paternal Cousin 5:
Paternal Cousin 6:

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
Sister 1:
Sister 2:
Sister 3:
Sister 4:
Sister 5:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Maternal Aunt 4:
Maternal Uncle 1:
Maternal Uncle 2:
Paternal Aunt 1:
Paternal Aunt 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:
Maternal Cousin 7:
Maternal Cousin 8:
Maternal Cousin 9:
Maternal Cousin 10:
Maternal Cousin 11:
Maternal Cousin 12:
Maternal Cousin 13:
Maternal Cousin 14:
Maternal Cousin 15:
Maternal Cousin 16:
Maternal Cousin 17:
Maternal Cousin 18:
Paternal Cousin 1:
Paternal Cousin 2:
Paternal Cousin 3:
Paternal Cousin 4:
Paternal Cousin 5:
Paternal Cousin 6:

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
Sister 1:
Sister 2:
Sister 3:
Sister 4:
Sister 5:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Maternal Aunt 4:
Maternal Uncle 1:
Maternal Uncle 2:
Paternal Aunt 1:
Paternal Aunt 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:
Maternal Cousin 7:
Maternal Cousin 8:
Maternal Cousin 9:
Maternal Cousin 10:
Maternal Cousin 11:
Maternal Cousin 12:
Maternal Cousin 13:
Maternal Cousin 14:
Maternal Cousin 15:
Maternal Cousin 16:
Maternal Cousin 17:
Maternal Cousin 18:
Paternal Cousin 1:
Paternal Cousin 2:
Paternal Cousin 3:
Paternal Cousin 4:
Paternal Cousin 5:
Paternal Cousin 6:

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
Sister 1:
Sister 2:
Sister 3:
Sister 4:
Sister 5:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Maternal Aunt 4:
Maternal Uncle 1:
Maternal Uncle 2:
Paternal Aunt 1:
Paternal Aunt 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:
Maternal Cousin 7:
Maternal Cousin 8:
Maternal Cousin 9:
Maternal Cousin 10:
Maternal Cousin 11:
Maternal Cousin 12:
Maternal Cousin 13:
Maternal Cousin 14:
Maternal Cousin 15:
Maternal Cousin 16:
Maternal Cousin 17:
Maternal Cousin 18:
Paternal Cousin 1:
Paternal Cousin 2:
Paternal Cousin 3:
Paternal Cousin 4:
Paternal Cousin 5:
Paternal Cousin 6:

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
Sister 1:
Sister 2:
Sister 3:
Sister 4:
Sister 5:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Maternal Aunt 4:
Maternal Uncle 1:
Maternal Uncle 2:
Paternal Aunt 1:
Paternal Aunt 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:
Maternal Cousin 7:
Maternal Cousin 8:
Maternal Cousin 9:
Maternal Cousin 10:
Maternal Cousin 11:
Maternal Cousin 12:
Maternal Cousin 13:
Maternal Cousin 14:
Maternal Cousin 15:
Maternal Cousin 16:
Maternal Cousin 17:
Maternal Cousin 18:
Paternal Cousin 1:
Paternal Cousin 2:
Paternal Cousin 3:
Paternal Cousin 4:
Paternal Cousin 5:
Paternal Cousin 6:

Medical History: Skin

Relative Acne
(age of onset)
Scarring Acne
(age of onset)
Eczema
(age of onset)
Psoriasis
(age of onset)
Self
Mother
Father 20's
Sister 1:
Sister 2:
Sister 3:
Sister 4:
Sister 5:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Maternal Aunt 4:
Maternal Uncle 1:
Maternal Uncle 2:
Paternal Aunt 1:
Paternal Aunt 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:
Maternal Cousin 7:
Maternal Cousin 8:
Maternal Cousin 9:
Maternal Cousin 10: Teens
Maternal Cousin 11:
Maternal Cousin 12:
Maternal Cousin 13:
Maternal Cousin 14:
Maternal Cousin 15:
Maternal Cousin 16:
Maternal Cousin 17:
Maternal Cousin 18:
Paternal Cousin 1:
Paternal Cousin 2:
Paternal Cousin 3:
Paternal Cousin 4:
Paternal Cousin 5:
Paternal Cousin 6:

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
Sister 1:
Sister 2:
Sister 3:
Sister 4:
Sister 5:
Maternal Grandmother
Maternal Grandfather 60's
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Maternal Aunt 4:
Maternal Uncle 1:
Maternal Uncle 2:
Paternal Aunt 1:
Paternal Aunt 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:
Maternal Cousin 7:
Maternal Cousin 8:
Maternal Cousin 9:
Maternal Cousin 10:
Maternal Cousin 11:
Maternal Cousin 12:
Maternal Cousin 13:
Maternal Cousin 14:
Maternal Cousin 15:
Maternal Cousin 16:
Maternal Cousin 17:
Maternal Cousin 18:
Paternal Cousin 1:
Paternal Cousin 2:
Paternal Cousin 3:
Paternal Cousin 4:
Paternal Cousin 5:
Paternal Cousin 6:

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
Sister 1:
Sister 2:
Sister 3:
Sister 4:
Sister 5:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Maternal Aunt 4:
Maternal Uncle 1:
Maternal Uncle 2:
Paternal Aunt 1:
Paternal Aunt 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:
Maternal Cousin 7:
Maternal Cousin 8:
Maternal Cousin 9:
Maternal Cousin 10:
Maternal Cousin 11:
Maternal Cousin 12:
Maternal Cousin 13:
Maternal Cousin 14:
Maternal Cousin 15:
Maternal Cousin 16:
Maternal Cousin 17:
Maternal Cousin 18:
Paternal Cousin 1:
Paternal Cousin 2:
Paternal Cousin 3:
Paternal Cousin 4:
Paternal Cousin 5:
Paternal Cousin 6:

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
Sister 1:
Sister 2:
Sister 3:
Sister 4:
Sister 5:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Maternal Aunt 4:
Maternal Uncle 1:
Maternal Uncle 2:
Paternal Aunt 1:
Paternal Aunt 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:
Maternal Cousin 7:
Maternal Cousin 8:
Maternal Cousin 9:
Maternal Cousin 10:
Maternal Cousin 11:
Maternal Cousin 12:
Maternal Cousin 13:
Maternal Cousin 14:
Maternal Cousin 15:
Maternal Cousin 16:
Maternal Cousin 17:
Maternal Cousin 18:
Paternal Cousin 1:
Paternal Cousin 2:
Paternal Cousin 3:
Paternal Cousin 4:
Paternal Cousin 5:
Paternal Cousin 6:

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
Sister 1:
Sister 2:
Sister 3:
Sister 4:
Sister 5:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Maternal Aunt 4:
Maternal Uncle 1:
Maternal Uncle 2:
Paternal Aunt 1:
Paternal Aunt 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:
Maternal Cousin 7:
Maternal Cousin 8:
Maternal Cousin 9:
Maternal Cousin 10:
Maternal Cousin 11:
Maternal Cousin 12:
Maternal Cousin 13:
Maternal Cousin 14:
Maternal Cousin 15:
Maternal Cousin 16:
Maternal Cousin 17:
Maternal Cousin 18:
Paternal Cousin 1:
Paternal Cousin 2:
Paternal Cousin 3:
Paternal Cousin 4:
Paternal Cousin 5:
Paternal Cousin 6:

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
Sister 1:
Sister 2:
Sister 3:
Sister 4:
Sister 5:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Maternal Aunt 4:
Maternal Uncle 1:
Maternal Uncle 2:
Paternal Aunt 1:
Paternal Aunt 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:
Maternal Cousin 7:
Maternal Cousin 8:
Maternal Cousin 9:
Maternal Cousin 10:
Maternal Cousin 11:
Maternal Cousin 12:
Maternal Cousin 13:
Maternal Cousin 14:
Maternal Cousin 15:
Maternal Cousin 16:
Maternal Cousin 17:
Maternal Cousin 18:
Paternal Cousin 1:
Paternal Cousin 2:
Paternal Cousin 3:
Paternal Cousin 4:
Paternal Cousin 5:
Paternal Cousin 6:

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
Sister 1:
Sister 2:
Sister 3:
Sister 4:
Sister 5:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Maternal Aunt 4:
Maternal Uncle 1:
Maternal Uncle 2:
Paternal Aunt 1:
Paternal Aunt 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:
Maternal Cousin 7:
Maternal Cousin 8:
Maternal Cousin 9:
Maternal Cousin 10:
Maternal Cousin 11:
Maternal Cousin 12:
Maternal Cousin 13:
Maternal Cousin 14:
Maternal Cousin 15:
Maternal Cousin 16:
Maternal Cousin 17:
Maternal Cousin 18:
Paternal Cousin 1:
Paternal Cousin 2:
Paternal Cousin 3:
Paternal Cousin 4:
Paternal Cousin 5:
Paternal Cousin 6:

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
Sister 1:
Sister 2:
Sister 3:
Sister 4:
Sister 5:
Maternal Grandmother 80's 60's
Rheumatoid Arthritis
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Maternal Aunt 4:
Maternal Uncle 1:
Maternal Uncle 2:
Paternal Aunt 1:
Paternal Aunt 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:
Maternal Cousin 7:
Maternal Cousin 8:
Maternal Cousin 9:
Maternal Cousin 10:
Maternal Cousin 11:
Maternal Cousin 12:
Maternal Cousin 13:
Maternal Cousin 14:
Maternal Cousin 15:
Maternal Cousin 16:
Maternal Cousin 17:
Maternal Cousin 18:
Paternal Cousin 1:
Paternal Cousin 2:
Paternal Cousin 3:
Paternal Cousin 4:
Paternal Cousin 5:
Paternal Cousin 6:

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

Relative Myasthenia Gravis
(age of onset)
Other Muscle/Bone/Joint Disorder
(age of onset & disorder)
Self
Mother
Father
Sister 1:
Sister 2:
Sister 3:
Sister 4:
Sister 5:
Maternal Grandmother 70's Osteoarthritis
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Maternal Aunt 4:
Maternal Uncle 1:
Maternal Uncle 2:
Paternal Aunt 1:
Paternal Aunt 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:
Maternal Cousin 7:
Maternal Cousin 8:
Maternal Cousin 9:
Maternal Cousin 10:
Maternal Cousin 11:
Maternal Cousin 12:
Maternal Cousin 13:
Maternal Cousin 14:
Maternal Cousin 15:
Maternal Cousin 16:
Maternal Cousin 17:
Maternal Cousin 18:
Paternal Cousin 1:
Paternal Cousin 2:
Paternal Cousin 3:
Paternal Cousin 4:
Paternal Cousin 5:
Paternal Cousin 6:

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
Sister 1:
Sister 2:
Sister 3:
Sister 4:
Sister 5:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Maternal Aunt 4:
Maternal Uncle 1:
Maternal Uncle 2:
Paternal Aunt 1:
Paternal Aunt 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:
Maternal Cousin 7:
Maternal Cousin 8:
Maternal Cousin 9:
Maternal Cousin 10:
Maternal Cousin 11:
Maternal Cousin 12:
Maternal Cousin 13:
Maternal Cousin 14:
Maternal Cousin 15:
Maternal Cousin 16:
Maternal Cousin 17:
Maternal Cousin 18:
Paternal Cousin 1:
Paternal Cousin 2:
Paternal Cousin 3:
Paternal Cousin 4:
Paternal Cousin 5:
Paternal Cousin 6:

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
Sister 1:
Sister 2:
Sister 3:
Sister 4:
Sister 5:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Maternal Aunt 4:
Maternal Uncle 1:
Maternal Uncle 2:
Paternal Aunt 1:
Paternal Aunt 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:
Maternal Cousin 7:
Maternal Cousin 8:
Maternal Cousin 9:
Maternal Cousin 10:
Maternal Cousin 11:
Maternal Cousin 12:
Maternal Cousin 13:
Maternal Cousin 14:
Maternal Cousin 15:
Maternal Cousin 16:
Maternal Cousin 17:
Maternal Cousin 18:
Paternal Cousin 1:
Paternal Cousin 2:
Paternal Cousin 3:
Paternal Cousin 4:
Paternal Cousin 5:
Paternal Cousin 6:

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

Relative Other Sight/Hearing/Olfactory Disorder
(age of onset & disorder)
Self
Mother
Father
Sister 1:
Sister 2:
Sister 3:
Sister 4:
Sister 5:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Maternal Aunt 4:
Maternal Uncle 1:
Maternal Uncle 2:
Paternal Aunt 1:
Paternal Aunt 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:
Maternal Cousin 7:
Maternal Cousin 8:
Maternal Cousin 9:
Maternal Cousin 10:
Maternal Cousin 11:
Maternal Cousin 12:
Maternal Cousin 13:
Maternal Cousin 14:
Maternal Cousin 15:
Maternal Cousin 16:
Maternal Cousin 17:
Maternal Cousin 18:
Paternal Cousin 1:
Paternal Cousin 2:
Paternal Cousin 3:
Paternal Cousin 4:
Paternal Cousin 5:
Paternal Cousin 6:

Medical History: Other

Relative Alcoholism
(age of onset)
Drug Abuse or Addiction
(age of onset)
Smoker/Tobacco Use
(age of onset)
Self
Mother
Father
Sister 1:
Sister 2:
Sister 3:
Sister 4: Teens
Sister 5:
Maternal Grandmother 20's
Maternal Grandfather 30's
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Maternal Aunt 4:
Maternal Uncle 1:
Maternal Uncle 2:
Paternal Aunt 1:
Paternal Aunt 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:
Maternal Cousin 7:
Maternal Cousin 8:
Maternal Cousin 9:
Maternal Cousin 10:
Maternal Cousin 11:
Maternal Cousin 12:
Maternal Cousin 13:
Maternal Cousin 14:
Maternal Cousin 15:
Maternal Cousin 16:
Maternal Cousin 17:
Maternal Cousin 18:
Paternal Cousin 1:
Paternal Cousin 2:
Paternal Cousin 3:
Paternal Cousin 4:
Paternal Cousin 5:
Paternal Cousin 6:

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
Sister 1:
Sister 2:
Sister 3:
Sister 4:
Sister 5:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Maternal Aunt 4:
Maternal Uncle 1:
Maternal Uncle 2:
Paternal Aunt 1:
Paternal Aunt 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:
Maternal Cousin 7:
Maternal Cousin 8: Teens
Maternal Cousin 9:
Maternal Cousin 10:
Maternal Cousin 11:
Maternal Cousin 12:
Maternal Cousin 13:
Maternal Cousin 14:
Maternal Cousin 15:
Maternal Cousin 16:
Maternal Cousin 17:
Maternal Cousin 18:
Paternal Cousin 1:
Paternal Cousin 2:
Paternal Cousin 3:
Paternal Cousin 4:
Paternal Cousin 5:
Paternal Cousin 6: