Donor Number 638

General Information

Donor Code:

638

Ethnic Origin:

English, German, Irish, Welsh

Blood Type:

O Positive

Hair Color:

Light Brown

Type of Hair:

Wavy

Thickness of Hair:

Average

Age at Time of Retrieval:

22-24

Eye Color:

Green

Complexion Relative to Race:

Medium

Bone Structure:

Medium

Height:

5'9"

Weight:

160

Handedness:

Right-Handed

Interests

Playing sports, volunteering, spending time with family, and scrap-booking.

Education

Education Status: High School Diploma Obtained

Area of Study: Human Resource Management

General Health

Vision: Good, does wear lenses

Hearing: Excellent

Dentition: Good, no 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.

Family Health

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

Paternal Grandmother: Alive and in her 80's, Healthy

Maternal Grandfather: Died in his 80's, Pneumonia

Maternal Grandmother: Alive and in her 70's, Healthy

Father: Alive and in his 40's, Healthy

Mother: Alive and in her 40's, Migraines (treated with ibuprofen), rheumatoid arthritis in her 40s

Siblings: At least one sibling, all in good health.

Genetic Screening Performed: Yes

This donor has been screened for 102 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 2/24/2014.

UPDATED HEALTH HISTORY:

No new information reported at this time.

Donation and Fertility

Donor Communication (Type): Open

Limited Available? No

Past Pregnancy: Yes

Staff Impressions

Face: Oval shape with two small moles on right cheek

Lips: Full upper and lower lips

Nose: Longer than average in length with slightly wider rounded tip

Ears: Larger in size, partially attached lobes, not tucked back

Eyes: Round almond shape, medium size, average set, with medium length eye lashes

Eyebrows: Medium fullness, curved

Summary: Very sweet girl, and very much on top of things! She always strives to be ahead of the game and seems to be very proactive in every aspect of life. This donor has been tested for BRCA1 and BRCA2 with negative results for both.

Donor Writing Sample/Essay

Childhood Photos

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Expanded Profile

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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:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Maternal Aunt 4:
Maternal Uncle 1:
Paternal Aunt 1:
Paternal Aunt 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:
Paternal Cousin 1:
Paternal Cousin 2:
Paternal Cousin 3:
Paternal Cousin 4:

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:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Maternal Aunt 4:
Maternal Uncle 1:
Paternal Aunt 1:
Paternal Aunt 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:
Paternal Cousin 1:
Paternal Cousin 2:
Paternal Cousin 3:
Paternal Cousin 4:

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:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Maternal Aunt 4:
Maternal Uncle 1:
Paternal Aunt 1:
Paternal Aunt 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:
Paternal Cousin 1:
Paternal Cousin 2:
Paternal Cousin 3:
Paternal Cousin 4:

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:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Maternal Aunt 4:
Maternal Uncle 1:
Paternal Aunt 1:
Paternal Aunt 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:
Paternal Cousin 1:
Paternal Cousin 2:
Paternal Cousin 3:
Paternal Cousin 4:

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:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Maternal Aunt 4:
Maternal Uncle 1:
Paternal Aunt 1:
Paternal Aunt 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:
Paternal Cousin 1:
Paternal Cousin 2:
Paternal Cousin 3:
Paternal Cousin 4:

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:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:				30's
Maternal Aunt 3:
Maternal Aunt 4:
Maternal Uncle 1:
Paternal Aunt 1:
Paternal Aunt 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:
Paternal Cousin 1:
Paternal Cousin 2:
Paternal Cousin 3:
Paternal Cousin 4:

Medical History: Blood (cont.)

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

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:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Maternal Aunt 4:
Maternal Uncle 1:
Paternal Aunt 1:
Paternal Aunt 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:
Paternal Cousin 1:
Paternal Cousin 2:
Paternal Cousin 3:
Paternal Cousin 4:

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:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Maternal Aunt 4:
Maternal Uncle 1:
Paternal Aunt 1:
Paternal Aunt 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:
Paternal Cousin 1:
Paternal Cousin 2:
Paternal Cousin 3:
Paternal Cousin 4:

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:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Maternal Aunt 4:
Maternal Uncle 1:
Paternal Aunt 1:
Paternal Aunt 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:
Paternal Cousin 1:
Paternal Cousin 2:
Paternal Cousin 3:
Paternal Cousin 4:

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:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Maternal Aunt 4:
Maternal Uncle 1:
Paternal Aunt 1:
Paternal Aunt 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:
Paternal Cousin 1:
Paternal Cousin 2:
Paternal Cousin 3:
Paternal Cousin 4:

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:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Maternal Aunt 4:
Maternal Uncle 1:
Paternal Aunt 1:
Paternal Aunt 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:
Paternal Cousin 1:
Paternal Cousin 2:
Paternal Cousin 3:
Paternal Cousin 4:

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:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Maternal Aunt 4:
Maternal Uncle 1:
Paternal Aunt 1:
Paternal Aunt 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:
Paternal Cousin 1:
Paternal Cousin 2:
Paternal Cousin 3:
Paternal Cousin 4:

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:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Maternal Aunt 4:
Maternal Uncle 1:
Paternal Aunt 1:
Paternal Aunt 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:
Paternal Cousin 1:
Paternal Cousin 2:
Paternal Cousin 3:
Paternal Cousin 4:

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:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Maternal Aunt 4:
Maternal Uncle 1:
Paternal Aunt 1:
Paternal Aunt 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:
Paternal Cousin 1:
Paternal Cousin 2:
Paternal Cousin 3:
Paternal Cousin 4:

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:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Maternal Aunt 4:
Maternal Uncle 1:
Paternal Aunt 1:
Paternal Aunt 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:
Paternal Cousin 1:
Paternal Cousin 2:
Paternal Cousin 3:
Paternal Cousin 4:

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:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Maternal Aunt 4:
Maternal Uncle 1:
Paternal Aunt 1:
Paternal Aunt 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:
Paternal Cousin 1:
Paternal Cousin 2:
Paternal Cousin 3:
Paternal Cousin 4:

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:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Maternal Aunt 4:
Maternal Uncle 1:
Paternal Aunt 1:
Paternal Aunt 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:
Paternal Cousin 1:
Paternal Cousin 2:
Paternal Cousin 3:
Paternal Cousin 4:

Medical History: Skin

Relative	Acne (age of onset)	Scarring Acne (age of onset)	Eczema (age of onset)	Psoriasis (age of onset)
Self
Mother
Father
Sister 1:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Maternal Aunt 4:
Maternal Uncle 1:
Paternal Aunt 1:
Paternal Aunt 2:
Maternal Cousin 1:
Maternal Cousin 2:
Maternal Cousin 3:	Teens
Maternal Cousin 4:
Maternal Cousin 5:
Maternal Cousin 6:
Maternal Cousin 7:
Maternal Cousin 8:
Maternal Cousin 9:
Maternal Cousin 10:
Paternal Cousin 1:
Paternal Cousin 2:
Paternal Cousin 3:
Paternal Cousin 4:

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:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Maternal Aunt 4:
Maternal Uncle 1:
Paternal Aunt 1:
Paternal Aunt 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:
Paternal Cousin 1:
Paternal Cousin 2:
Paternal Cousin 3:
Paternal Cousin 4:

Medical History: Neurological

Relative	Migraines (age of onset)	Mental Retardation (age of onset)	Alzheimers (age of onset)	Multiple Sclerosis (age of onset)
Self
Mother	40's
Father
Sister 1:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Maternal Aunt 4:
Maternal Uncle 1:
Paternal Aunt 1:
Paternal Aunt 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:
Paternal Cousin 1:
Paternal Cousin 2:
Paternal Cousin 3:
Paternal Cousin 4:

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:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Maternal Aunt 4:
Maternal Uncle 1:
Paternal Aunt 1:
Paternal Aunt 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:
Paternal Cousin 1:
Paternal Cousin 2:
Paternal Cousin 3:
Paternal Cousin 4:

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:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Maternal Aunt 4:
Maternal Uncle 1:
Paternal Aunt 1:
Paternal Aunt 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:
Paternal Cousin 1:
Paternal Cousin 2:
Paternal Cousin 3:
Paternal Cousin 4:

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:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Maternal Aunt 4:
Maternal Uncle 1:
Paternal Aunt 1:
Paternal Aunt 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:
Paternal Cousin 1:
Paternal Cousin 2:
Paternal Cousin 3:
Paternal Cousin 4:

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:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Maternal Aunt 4:
Maternal Uncle 1:
Paternal Aunt 1:
Paternal Aunt 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:
Paternal Cousin 1:
Paternal Cousin 2:
Paternal Cousin 3:
Paternal Cousin 4:

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			40's
Father
Sister 1:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Maternal Aunt 4:
Maternal Uncle 1:
Paternal Aunt 1:
Paternal Aunt 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:
Paternal Cousin 1:
Paternal Cousin 2:
Paternal Cousin 3:
Paternal Cousin 4:

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:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Maternal Aunt 4:
Maternal Uncle 1:
Paternal Aunt 1:
Paternal Aunt 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:
Paternal Cousin 1:
Paternal Cousin 2:
Paternal Cousin 3:
Paternal Cousin 4:

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:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Maternal Aunt 4:
Maternal Uncle 1:
Paternal Aunt 1:
Paternal Aunt 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:
Paternal Cousin 1:
Paternal Cousin 2:
Paternal Cousin 3:
Paternal Cousin 4:

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:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Maternal Aunt 4:
Maternal Uncle 1:
Paternal Aunt 1:
Paternal Aunt 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:
Paternal Cousin 1:
Paternal Cousin 2:
Paternal Cousin 3:
Paternal Cousin 4:

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

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

Medical History: Other

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

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:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:			30's
Maternal Aunt 3:
Maternal Aunt 4:
Maternal Uncle 1:
Paternal Aunt 1:
Paternal Aunt 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:
Paternal Cousin 1:
Paternal Cousin 2:
Paternal Cousin 3:
Paternal Cousin 4: