Donor Number 527

General Information

Donor Code:
527
Ethnic Origin:
German, Native American, Norwegian, Scotch-Irish, Scottish
Blood Type:
O Positive
Hair Color:
Dark Blond
Type of Hair:
Straight
Thickness of Hair:
Average
Age at Time of Retrieval:
25-26
Eye Color:
Blue
Complexion Relative to Race:
Fair
Bone Structure:
Small
Height:
5'6"
Weight:
118
Handedness:
Right-Handed

She loves to write and draw. She is a storyteller at heart and wants to be an author. She loves learning new things and hopes to one day share her love of learning with her students.

Education Status: Associates Degree Obtained

Area of Study: Educational Studies, English, History

Vision: Excellent, does not wear lenses

Hearing: Excellent

Dentition: Excellent, no orthodontia required

Allergies: Cat

Hospitalization: None known

Alcohol Usage: Does drink alcohol; 0-3 Drinks per week

Tobacco Usage: Does not smoke

Drug Usage: Tests NEGATIVE for Drugs of Abuse.

Paternal Grandfather: Died in his 80's, Asbestos-related Mesothelioma. While in the hospital for respiratory issues, he caught an infection that lead to his death. Smoker

Paternal Grandmother: Died in her 60's, Lung cancer in her 60's, smoker.

Maternal Grandfather: Died in his 70's, Colon cancer in his late 60's.

Maternal Grandmother: Died in her 80's, Heart disease in her 70's. High blood pressure and arrhythmia in her 70's.

Father: Alive and in his 60's, Heart attack in his 60's. Heart disease in his 60's. Smoker

Mother: Alive and in her 50's, High blood pressure in her 40's, lifestyle related

Siblings: At least one, 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:

Smith-Lemli-Opitz Syndrome

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 4/19/2016.

UPDATED HEALTH HISTORY:

No new information reported at this time.

Donor Communication (Type): Open

Limited Available? No

Past Pregnancy: Yes

Face: Round, average in size. Average to high forehead set. Very, very slight sprinkle of barely there freckles across bridge of nose. No unique features and no cleft in chin.

Lips: Thin upper and lower lip.

Nose: Straight nose with very small bump in bridge. Average in size and average in length with small nostril flare.

Ears: Medium sized ears with attached lobe and average distance from face.

Eyes: Eyes are large and round with an average setting and long lashes.

Eyebrows: Eyebrows are thin with a curved shape.

Summary: It wouldn't be surprising if this donor were to become a best selling author one day, as reading and writing are her ultimate passions. Her exquisite personality matches her beautiful outer shell and striking up a conversation comes effortlessly to her. She has a driving desire to accomplish high set goals, such as completing her Doctorate in the near future.

 

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:
Maternal Grandmother
Maternal Grandfather Defect in his arm, was not handicapped.
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Maternal Uncle 1:
Paternal Aunt 1:
Paternal Aunt 2:
Paternal Uncle 1:
Paternal Uncle 2:
Paternal Uncle 3:
Paternal Uncle 4:
Maternal Cousin 1:
Maternal Cousin 2:
Maternal Cousin 3:
Maternal Cousin 4:
Maternal Cousin 5:
Paternal Cousin 1:
Paternal Cousin 2:
Paternal Cousin 3:
Paternal Cousin 4:
Paternal Cousin 5:
Paternal Cousin 6:
Paternal Cousin 7:
Paternal Cousin 8:
Paternal Cousin 9:
Paternal Cousin 10:
Paternal Cousin 11:
Paternal Cousin 12:
Paternal Cousin 13:
Paternal Cousin 14:

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 Heart Murmur, I outgrew it.
Mother
Father
Sister 1:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Maternal Uncle 1:
Paternal Aunt 1:
Paternal Aunt 2:
Paternal Uncle 1:
Paternal Uncle 2:
Paternal Uncle 3:
Paternal Uncle 4:
Maternal Cousin 1:
Maternal Cousin 2:
Maternal Cousin 3:
Maternal Cousin 4:
Maternal Cousin 5:
Paternal Cousin 1:
Paternal Cousin 2:
Paternal Cousin 3:
Paternal Cousin 4:
Paternal Cousin 5:
Paternal Cousin 6:
Paternal Cousin 7:
Paternal Cousin 8:
Paternal Cousin 9:
Paternal Cousin 10:
Paternal Cousin 11:
Paternal Cousin 12:
Paternal Cousin 13:
Paternal Cousin 14:

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 Uncle 1:
Paternal Aunt 1:
Paternal Aunt 2:
Paternal Uncle 1:
Paternal Uncle 2:
Paternal Uncle 3:
Paternal Uncle 4:
Maternal Cousin 1:
Maternal Cousin 2:
Maternal Cousin 3:
Maternal Cousin 4:
Maternal Cousin 5:
Paternal Cousin 1:
Paternal Cousin 2:
Paternal Cousin 3:
Paternal Cousin 4:
Paternal Cousin 5:
Paternal Cousin 6:
Paternal Cousin 7:
Paternal Cousin 8:
Paternal Cousin 9:
Paternal Cousin 10:
Paternal Cousin 11:
Paternal Cousin 12:
Paternal Cousin 13:
Paternal Cousin 14:

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 40's
Father 60's 60's 60's
Sister 1:
Maternal Grandmother 70's 70's 70's
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Maternal Uncle 1:
Paternal Aunt 1:
Paternal Aunt 2:
Paternal Uncle 1:
Paternal Uncle 2: 50's 50's
Paternal Uncle 3:
Paternal Uncle 4: 60's
Maternal Cousin 1:
Maternal Cousin 2:
Maternal Cousin 3:
Maternal Cousin 4:
Maternal Cousin 5:
Paternal Cousin 1:
Paternal Cousin 2:
Paternal Cousin 3:
Paternal Cousin 4:
Paternal Cousin 5:
Paternal Cousin 6:
Paternal Cousin 7:
Paternal Cousin 8:
Paternal Cousin 9:
Paternal Cousin 10:
Paternal Cousin 11:
Paternal Cousin 12:
Paternal Cousin 13:
Paternal Cousin 14:

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 Uncle 1:
Paternal Aunt 1:
Paternal Aunt 2:
Paternal Uncle 1:
Paternal Uncle 2:
Paternal Uncle 3:
Paternal Uncle 4:
Maternal Cousin 1:
Maternal Cousin 2:
Maternal Cousin 3:
Maternal Cousin 4:
Maternal Cousin 5:
Paternal Cousin 1:
Paternal Cousin 2:
Paternal Cousin 3:
Paternal Cousin 4:
Paternal Cousin 5:
Paternal Cousin 6:
Paternal Cousin 7:
Paternal Cousin 8:
Paternal Cousin 9:
Paternal Cousin 10:
Paternal Cousin 11:
Paternal Cousin 12:
Paternal Cousin 13:
Paternal Cousin 14:

Medical History: Blood

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

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 Uncle 1:
Paternal Aunt 1:
Paternal Aunt 2:
Paternal Uncle 1:
Paternal Uncle 2:
Paternal Uncle 3:
Paternal Uncle 4:
Maternal Cousin 1:
Maternal Cousin 2:
Maternal Cousin 3:
Maternal Cousin 4:
Maternal Cousin 5:
Paternal Cousin 1:
Paternal Cousin 2:
Paternal Cousin 3:
Paternal Cousin 4:
Paternal Cousin 5:
Paternal Cousin 6:
Paternal Cousin 7:
Paternal Cousin 8:
Paternal Cousin 9:
Paternal Cousin 10:
Paternal Cousin 11:
Paternal Cousin 12:
Paternal Cousin 13:
Paternal Cousin 14:

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 Uncle 1:
Paternal Aunt 1:
Paternal Aunt 2:
Paternal Uncle 1:
Paternal Uncle 2:
Paternal Uncle 3:
Paternal Uncle 4:
Maternal Cousin 1:
Maternal Cousin 2:
Maternal Cousin 3:
Maternal Cousin 4:
Maternal Cousin 5:
Paternal Cousin 1:
Paternal Cousin 2:
Paternal Cousin 3:
Paternal Cousin 4:
Paternal Cousin 5:
Paternal Cousin 6:
Paternal Cousin 7:
Paternal Cousin 8:
Paternal Cousin 9:
Paternal Cousin 10:
Paternal Cousin 11:
Paternal Cousin 12:
Paternal Cousin 13:
Paternal Cousin 14:

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 60's
Paternal Grandfather Asbestos-related Mesothelioma
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Maternal Uncle 1:
Paternal Aunt 1:
Paternal Aunt 2:
Paternal Uncle 1:
Paternal Uncle 2:
Paternal Uncle 3:
Paternal Uncle 4:
Maternal Cousin 1:
Maternal Cousin 2:
Maternal Cousin 3:
Maternal Cousin 4:
Maternal Cousin 5:
Paternal Cousin 1:
Paternal Cousin 2:
Paternal Cousin 3:
Paternal Cousin 4:
Paternal Cousin 5:
Paternal Cousin 6:
Paternal Cousin 7:
Paternal Cousin 8:
Paternal Cousin 9:
Paternal Cousin 10:
Paternal Cousin 11:
Paternal Cousin 12:
Paternal Cousin 13:
Paternal Cousin 14:

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: Pre-Teens
Maternal Uncle 1:
Paternal Aunt 1:
Paternal Aunt 2:
Paternal Uncle 1:
Paternal Uncle 2:
Paternal Uncle 3:
Paternal Uncle 4:
Maternal Cousin 1:
Maternal Cousin 2:
Maternal Cousin 3:
Maternal Cousin 4:
Maternal Cousin 5:
Paternal Cousin 1:
Paternal Cousin 2:
Paternal Cousin 3:
Paternal Cousin 4:
Paternal Cousin 5:
Paternal Cousin 6:
Paternal Cousin 7:
Paternal Cousin 8:
Paternal Cousin 9:
Paternal Cousin 10:
Paternal Cousin 11:
Paternal Cousin 12:
Paternal Cousin 13:
Paternal Cousin 14:

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

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 Uncle 1:
Paternal Aunt 1:
Paternal Aunt 2:
Paternal Uncle 1:
Paternal Uncle 2:
Paternal Uncle 3:
Paternal Uncle 4:
Maternal Cousin 1:
Maternal Cousin 2:
Maternal Cousin 3:
Maternal Cousin 4:
Maternal Cousin 5:
Paternal Cousin 1:
Paternal Cousin 2:
Paternal Cousin 3:
Paternal Cousin 4:
Paternal Cousin 5:
Paternal Cousin 6:
Paternal Cousin 7:
Paternal Cousin 8:
Paternal Cousin 9:
Paternal Cousin 10:
Paternal Cousin 11:
Paternal Cousin 12:
Paternal Cousin 13:
Paternal Cousin 14:

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 60's - Type 2 Diabetes
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Maternal Uncle 1:
Paternal Aunt 1:
Paternal Aunt 2:
Paternal Uncle 1: 50's - Type 2 Diabetes
Paternal Uncle 2:
Paternal Uncle 3:
Paternal Uncle 4:
Maternal Cousin 1:
Maternal Cousin 2:
Maternal Cousin 3:
Maternal Cousin 4:
Maternal Cousin 5:
Paternal Cousin 1:
Paternal Cousin 2:
Paternal Cousin 3:
Paternal Cousin 4:
Paternal Cousin 5:
Paternal Cousin 6:
Paternal Cousin 7:
Paternal Cousin 8:
Paternal Cousin 9:
Paternal Cousin 10:
Paternal Cousin 11:
Paternal Cousin 12:
Paternal Cousin 13:
Paternal Cousin 14:

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 Uncle 1:
Paternal Aunt 1:
Paternal Aunt 2:
Paternal Uncle 1:
Paternal Uncle 2:
Paternal Uncle 3:
Paternal Uncle 4:
Maternal Cousin 1:
Maternal Cousin 2:
Maternal Cousin 3:
Maternal Cousin 4:
Maternal Cousin 5:
Paternal Cousin 1:
Paternal Cousin 2:
Paternal Cousin 3:
Paternal Cousin 4:
Paternal Cousin 5:
Paternal Cousin 6:
Paternal Cousin 7:
Paternal Cousin 8:
Paternal Cousin 9:
Paternal Cousin 10:
Paternal Cousin 11:
Paternal Cousin 12:
Paternal Cousin 13:
Paternal Cousin 14:

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 Uncle 1:
Paternal Aunt 1:
Paternal Aunt 2:
Paternal Uncle 1:
Paternal Uncle 2:
Paternal Uncle 3:
Paternal Uncle 4:
Maternal Cousin 1:
Maternal Cousin 2:
Maternal Cousin 3:
Maternal Cousin 4:
Maternal Cousin 5:
Paternal Cousin 1:
Paternal Cousin 2:
Paternal Cousin 3:
Paternal Cousin 4:
Paternal Cousin 5:
Paternal Cousin 6:
Paternal Cousin 7:
Paternal Cousin 8:
Paternal Cousin 9:
Paternal Cousin 10:
Paternal Cousin 11:
Paternal Cousin 12:
Paternal Cousin 13:
Paternal Cousin 14:

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 Uncle 1:
Paternal Aunt 1:
Paternal Aunt 2:
Paternal Uncle 1:
Paternal Uncle 2:
Paternal Uncle 3:
Paternal Uncle 4:
Maternal Cousin 1:
Maternal Cousin 2:
Maternal Cousin 3:
Maternal Cousin 4:
Maternal Cousin 5:
Paternal Cousin 1:
Paternal Cousin 2:
Paternal Cousin 3:
Paternal Cousin 4:
Paternal Cousin 5:
Paternal Cousin 6:
Paternal Cousin 7:
Paternal Cousin 8:
Paternal Cousin 9:
Paternal Cousin 10:
Paternal Cousin 11:
Paternal Cousin 12:
Paternal Cousin 13:
Paternal Cousin 14:

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 Uncle 1:
Paternal Aunt 1:
Paternal Aunt 2:
Paternal Uncle 1:
Paternal Uncle 2:
Paternal Uncle 3:
Paternal Uncle 4:
Maternal Cousin 1:
Maternal Cousin 2:
Maternal Cousin 3:
Maternal Cousin 4:
Maternal Cousin 5:
Paternal Cousin 1:
Paternal Cousin 2:
Paternal Cousin 3:
Paternal Cousin 4:
Paternal Cousin 5:
Paternal Cousin 6:
Paternal Cousin 7:
Paternal Cousin 8:
Paternal Cousin 9:
Paternal Cousin 10:
Paternal Cousin 11:
Paternal Cousin 12:
Paternal Cousin 13:
Paternal Cousin 14:

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 Uncle 1:
Paternal Aunt 1:
Paternal Aunt 2:
Paternal Uncle 1:
Paternal Uncle 2:
Paternal Uncle 3:
Paternal Uncle 4:
Maternal Cousin 1:
Maternal Cousin 2:
Maternal Cousin 3:
Maternal Cousin 4:
Maternal Cousin 5:
Paternal Cousin 1:
Paternal Cousin 2:
Paternal Cousin 3:
Paternal Cousin 4:
Paternal Cousin 5:
Paternal Cousin 6:
Paternal Cousin 7:
Paternal Cousin 8:
Paternal Cousin 9:
Paternal Cousin 10:
Paternal Cousin 11:
Paternal Cousin 12:
Paternal Cousin 13:
Paternal Cousin 14:

Medical History: Skin

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

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 Uncle 1:
Paternal Aunt 1:
Paternal Aunt 2:
Paternal Uncle 1:
Paternal Uncle 2:
Paternal Uncle 3:
Paternal Uncle 4:
Maternal Cousin 1:
Maternal Cousin 2:
Maternal Cousin 3:
Maternal Cousin 4:
Maternal Cousin 5:
Paternal Cousin 1:
Paternal Cousin 2:
Paternal Cousin 3:
Paternal Cousin 4:
Paternal Cousin 5:
Paternal Cousin 6:
Paternal Cousin 7:
Paternal Cousin 8:
Paternal Cousin 9:
Paternal Cousin 10:
Paternal Cousin 11:
Paternal Cousin 12:
Paternal Cousin 13:
Paternal Cousin 14:

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

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 Uncle 1:
Paternal Aunt 1:
Paternal Aunt 2:
Paternal Uncle 1:
Paternal Uncle 2:
Paternal Uncle 3:
Paternal Uncle 4:
Maternal Cousin 1:
Maternal Cousin 2:
Maternal Cousin 3:
Maternal Cousin 4:
Maternal Cousin 5:
Paternal Cousin 1:
Paternal Cousin 2:
Paternal Cousin 3:
Paternal Cousin 4:
Paternal Cousin 5:
Paternal Cousin 6:
Paternal Cousin 7:
Paternal Cousin 8:
Paternal Cousin 9:
Paternal Cousin 10:
Paternal Cousin 11:
Paternal Cousin 12:
Paternal Cousin 13:
Paternal Cousin 14:

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 Uncle 1:
Paternal Aunt 1:
Paternal Aunt 2:
Paternal Uncle 1:
Paternal Uncle 2:
Paternal Uncle 3:
Paternal Uncle 4:
Maternal Cousin 1:
Maternal Cousin 2:
Maternal Cousin 3:
Maternal Cousin 4:
Maternal Cousin 5:
Paternal Cousin 1:
Paternal Cousin 2:
Paternal Cousin 3:
Paternal Cousin 4:
Paternal Cousin 5:
Paternal Cousin 6:
Paternal Cousin 7:
Paternal Cousin 8:
Paternal Cousin 9:
Paternal Cousin 10:
Paternal Cousin 11:
Paternal Cousin 12:
Paternal Cousin 13:
Paternal Cousin 14:

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

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 Uncle 1:
Paternal Aunt 1:
Paternal Aunt 2:
Paternal Uncle 1:
Paternal Uncle 2:
Paternal Uncle 3:
Paternal Uncle 4:
Maternal Cousin 1:
Maternal Cousin 2:
Maternal Cousin 3:
Maternal Cousin 4:
Maternal Cousin 5:
Paternal Cousin 1:
Paternal Cousin 2:
Paternal Cousin 3:
Paternal Cousin 4:
Paternal Cousin 5:
Paternal Cousin 6:
Paternal Cousin 7:
Paternal Cousin 8:
Paternal Cousin 9:
Paternal Cousin 10:
Paternal Cousin 11:
Paternal Cousin 12:
Paternal Cousin 13:
Paternal Cousin 14:

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

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 Uncle 1:
Paternal Aunt 1:
Paternal Aunt 2:
Paternal Uncle 1:
Paternal Uncle 2:
Paternal Uncle 3:
Paternal Uncle 4:
Maternal Cousin 1:
Maternal Cousin 2:
Maternal Cousin 3:
Maternal Cousin 4:
Maternal Cousin 5:
Paternal Cousin 1:
Paternal Cousin 2:
Paternal Cousin 3:
Paternal Cousin 4:
Paternal Cousin 5:
Paternal Cousin 6:
Paternal Cousin 7:
Paternal Cousin 8:
Paternal Cousin 9:
Paternal Cousin 10:
Paternal Cousin 11:
Paternal Cousin 12:
Paternal Cousin 13:
Paternal Cousin 14:

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 Uncle 1:
Paternal Aunt 1:
Paternal Aunt 2:
Paternal Uncle 1:
Paternal Uncle 2:
Paternal Uncle 3:
Paternal Uncle 4:
Maternal Cousin 1:
Maternal Cousin 2:
Maternal Cousin 3:
Maternal Cousin 4:
Maternal Cousin 5:
Paternal Cousin 1:
Paternal Cousin 2:
Paternal Cousin 3:
Paternal Cousin 4:
Paternal Cousin 5:
Paternal Cousin 6:
Paternal Cousin 7:
Paternal Cousin 8:
Paternal Cousin 9:
Paternal Cousin 10:
Paternal Cousin 11:
Paternal Cousin 12:
Paternal Cousin 13:
Paternal Cousin 14:

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 Uncle 1: Pre-Teens
Paternal Aunt 1:
Paternal Aunt 2:
Paternal Uncle 1:
Paternal Uncle 2:
Paternal Uncle 3:
Paternal Uncle 4:
Maternal Cousin 1:
Maternal Cousin 2:
Maternal Cousin 3:
Maternal Cousin 4:
Maternal Cousin 5:
Paternal Cousin 1:
Paternal Cousin 2:
Paternal Cousin 3:
Paternal Cousin 4:
Paternal Cousin 5:
Paternal Cousin 6:
Paternal Cousin 7:
Paternal Cousin 8:
Paternal Cousin 9:
Paternal Cousin 10:
Paternal Cousin 11:
Paternal Cousin 12:
Paternal Cousin 13:
Paternal Cousin 14:

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 Uncle 1:
Paternal Aunt 1:
Paternal Aunt 2:
Paternal Uncle 1:
Paternal Uncle 2:
Paternal Uncle 3:
Paternal Uncle 4:
Maternal Cousin 1:
Maternal Cousin 2:
Maternal Cousin 3:
Maternal Cousin 4:
Maternal Cousin 5:
Paternal Cousin 1:
Paternal Cousin 2:
Paternal Cousin 3:
Paternal Cousin 4:
Paternal Cousin 5:
Paternal Cousin 6:
Paternal Cousin 7:
Paternal Cousin 8:
Paternal Cousin 9:
Paternal Cousin 10:
Paternal Cousin 11:
Paternal Cousin 12:
Paternal Cousin 13:
Paternal Cousin 14:

Medical History: Other

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

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 20's
Mother 20's
Father 20's
Sister 1:
Maternal Grandmother
Maternal Grandfather 70's Colon Cancer
Paternal Grandmother 60's Lung Cancer
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Maternal Uncle 1:
Paternal Aunt 1:
Paternal Aunt 2:
Paternal Uncle 1:
Paternal Uncle 2:
Paternal Uncle 3:
Paternal Uncle 4:
Maternal Cousin 1:
Maternal Cousin 2:
Maternal Cousin 3:
Maternal Cousin 4:
Maternal Cousin 5:
Paternal Cousin 1:
Paternal Cousin 2:
Paternal Cousin 3:
Paternal Cousin 4:
Paternal Cousin 5:
Paternal Cousin 6:
Paternal Cousin 7:
Paternal Cousin 8:
Paternal Cousin 9:
Paternal Cousin 10:
Paternal Cousin 11:
Paternal Cousin 12:
Paternal Cousin 13:
Paternal Cousin 14: