For a limited time only receive 25%
off your purchase of 6+ eggs. Call us at 800-786-5251 to place your order today!
Writing is her passion especially poetry. She really enjoys dogs and has one herself. Travel, volleyball, basketball, singing and family.
Education Status: High School Diploma Obtained
Area of Study: General Studies, Undeclared Major
Vision: Fair, does wear lenses
Hearing: Good
Dentition: Excellent, orthodontia required
Allergies: Grass
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: Alive and in his 70's, Healthy
Paternal Grandmother: Alive and in her 70's, Healthy
Maternal Grandfather: Alive and in his 60's, Healthy, osteoarthritis
Maternal Grandmother: Died in her 60's, She died of emphysema, she was a smoker
Father: Alive and in his 40's, Healthy
Mother: Alive and in her 40's, Healthy, occasional migraines, asthma
Siblings: at least one sibling, all in good health, occasional migraines
Genetic Screening Performed: Yes
Donor Communication (Type): Open
Limited Available? Fewer than 6 eggs available
Past Pregnancy: Yes
Face: Oval face and more on the fair side.
Lips: Lips are equally medium in fullness. She has perfectly straight teeth that are medium in size.
Nose: Straight and medium in flare. Average in size.
Ears: Average size, tucked back, detached lobes
Eyes: Almond green eyes that are small to medium in size. Nice full eyelashes.
Eyebrows: Slightly arched and medium to thin in fullness.
Summary: She is easy to talk to and seems very kind to people. She has a good strong attitude toward life and is ready to live it to the fullest. She also has absolutely gorgeous eyes.
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: | ||||
Maternal Grandmother | ||||
Maternal Grandfather | ||||
Paternal Grandmother | ||||
Paternal Grandfather | ||||
Maternal Uncle 1: | ||||
Paternal Aunt 1: | ||||
Paternal Uncle 1: | ||||
Maternal Cousin 1: | ||||
Maternal Cousin 2: | ||||
Maternal Cousin 3: | ||||
Paternal Cousin 1: | ||||
Paternal Cousin 2: | ||||
Paternal Cousin 3: | ||||
Paternal Cousin 4: | ||||
Paternal Cousin 5: |
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: | ||||
Sister 1: | ||||
Maternal Grandmother | ||||
Maternal Grandfather | ||||
Paternal Grandmother | ||||
Paternal Grandfather | ||||
Maternal Uncle 1: | ||||
Paternal Aunt 1: | ||||
Paternal Uncle 1: | ||||
Maternal Cousin 1: | ||||
Maternal Cousin 2: | ||||
Maternal Cousin 3: | ||||
Paternal Cousin 1: | ||||
Paternal Cousin 2: | ||||
Paternal Cousin 3: | ||||
Paternal Cousin 4: | ||||
Paternal Cousin 5: |
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: | |||
Maternal Grandmother | |||
Maternal Grandfather | |||
Paternal Grandmother | |||
Paternal Grandfather | |||
Maternal Uncle 1: | |||
Paternal Aunt 1: | |||
Paternal Uncle 1: | |||
Maternal Cousin 1: | |||
Maternal Cousin 2: | |||
Maternal Cousin 3: | |||
Paternal Cousin 1: | |||
Paternal Cousin 2: | |||
Paternal Cousin 3: | |||
Paternal Cousin 4: | |||
Paternal Cousin 5: |
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: | ||||
Maternal Grandmother | ||||
Maternal Grandfather | ||||
Paternal Grandmother | ||||
Paternal Grandfather | ||||
Maternal Uncle 1: | ||||
Paternal Aunt 1: | ||||
Paternal Uncle 1: | ||||
Maternal Cousin 1: | ||||
Maternal Cousin 2: | ||||
Maternal Cousin 3: | ||||
Paternal Cousin 1: | ||||
Paternal Cousin 2: | ||||
Paternal Cousin 3: | ||||
Paternal Cousin 4: | ||||
Paternal Cousin 5: |
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: | ||||
Maternal Grandmother | ||||
Maternal Grandfather | ||||
Paternal Grandmother | ||||
Paternal Grandfather | ||||
Maternal Uncle 1: | ||||
Paternal Aunt 1: | ||||
Paternal Uncle 1: | ||||
Maternal Cousin 1: | ||||
Maternal Cousin 2: | ||||
Maternal Cousin 3: | ||||
Paternal Cousin 1: | ||||
Paternal Cousin 2: | ||||
Paternal Cousin 3: | ||||
Paternal Cousin 4: | ||||
Paternal Cousin 5: |
Relative | Anemia (age of onset) |
Sickle Cell (age of onset) |
Hemophilia (age of onset) |
Leukemia (age of onset) |
---|---|---|---|---|
Self | ||||
Mother | ||||
Father | ||||
Brother 1: | ||||
Sister 1: | ||||
Maternal Grandmother | ||||
Maternal Grandfather | ||||
Paternal Grandmother | ||||
Paternal Grandfather | ||||
Maternal Uncle 1: | ||||
Paternal Aunt 1: | ||||
Paternal Uncle 1: | ||||
Maternal Cousin 1: | ||||
Maternal Cousin 2: | ||||
Maternal Cousin 3: | ||||
Paternal Cousin 1: | ||||
Paternal Cousin 2: | ||||
Paternal Cousin 3: | ||||
Paternal Cousin 4: | ||||
Paternal Cousin 5: |
Relative | Immune Problems (age of onset) |
Other Blood Disorder (age of onset & disorder) |
---|---|---|
Self | ||
Mother | ||
Father | ||
Brother 1: | ||
Sister 1: | ||
Maternal Grandmother | ||
Maternal Grandfather | ||
Paternal Grandmother | ||
Paternal Grandfather | ||
Maternal Uncle 1: | ||
Paternal Aunt 1: | ||
Paternal Uncle 1: | ||
Maternal Cousin 1: | ||
Maternal Cousin 2: | ||
Maternal Cousin 3: | ||
Paternal Cousin 1: | ||
Paternal Cousin 2: | ||
Paternal Cousin 3: | ||
Paternal Cousin 4: | ||
Paternal Cousin 5: |
Relative | Hay Fever (age of onset) |
Asthma (age of onset) |
Emphysema (age of onset) |
Tuberculosis (age of onset) |
---|---|---|---|---|
Self | ||||
Mother | 20s | |||
Father | ||||
Brother 1: | ||||
Sister 1: | ||||
Maternal Grandmother | 60s | |||
Maternal Grandfather | ||||
Paternal Grandmother | ||||
Paternal Grandfather | ||||
Maternal Uncle 1: | ||||
Paternal Aunt 1: | ||||
Paternal Uncle 1: | ||||
Maternal Cousin 1: | ||||
Maternal Cousin 2: | ||||
Maternal Cousin 3: | ||||
Paternal Cousin 1: | ||||
Paternal Cousin 2: | ||||
Paternal Cousin 3: | ||||
Paternal Cousin 4: | ||||
Paternal Cousin 5: |
Relative | Lung Cancer (age of onset) |
Pneumonia (age of onset) |
Other Respiratory Disorder (age of onset & disorder) |
---|---|---|---|
Self | |||
Mother | |||
Father | |||
Brother 1: | |||
Sister 1: | |||
Maternal Grandmother | |||
Maternal Grandfather | |||
Paternal Grandmother | |||
Paternal Grandfather | |||
Maternal Uncle 1: | |||
Paternal Aunt 1: | |||
Paternal Uncle 1: | |||
Maternal Cousin 1: | |||
Maternal Cousin 2: | |||
Maternal Cousin 3: | |||
Paternal Cousin 1: | |||
Paternal Cousin 2: | |||
Paternal Cousin 3: | |||
Paternal Cousin 4: | |||
Paternal Cousin 5: |
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: | ||||
Maternal Grandmother | ||||
Maternal Grandfather | ||||
Paternal Grandmother | ||||
Paternal Grandfather | ||||
Maternal Uncle 1: | ||||
Paternal Aunt 1: | ||||
Paternal Uncle 1: | ||||
Maternal Cousin 1: | ||||
Maternal Cousin 2: | ||||
Maternal Cousin 3: | ||||
Paternal Cousin 1: | ||||
Paternal Cousin 2: | ||||
Paternal Cousin 3: | ||||
Paternal Cousin 4: | ||||
Paternal Cousin 5: |
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: | ||||
Maternal Grandmother | ||||
Maternal Grandfather | ||||
Paternal Grandmother | ||||
Paternal Grandfather | ||||
Maternal Uncle 1: | ||||
Paternal Aunt 1: | ||||
Paternal Uncle 1: | ||||
Maternal Cousin 1: | ||||
Maternal Cousin 2: | ||||
Maternal Cousin 3: | ||||
Paternal Cousin 1: | ||||
Paternal Cousin 2: | ||||
Paternal Cousin 3: | ||||
Paternal Cousin 4: | ||||
Paternal Cousin 5: |
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: | |||
Maternal Grandmother | |||
Maternal Grandfather | |||
Paternal Grandmother | |||
Paternal Grandfather | |||
Maternal Uncle 1: | |||
Paternal Aunt 1: | |||
Paternal Uncle 1: | |||
Maternal Cousin 1: | |||
Maternal Cousin 2: | |||
Maternal Cousin 3: | |||
Paternal Cousin 1: | |||
Paternal Cousin 2: | |||
Paternal Cousin 3: | |||
Paternal Cousin 4: | |||
Paternal Cousin 5: |
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: | ||||
Maternal Grandmother | ||||
Maternal Grandfather | ||||
Paternal Grandmother | ||||
Paternal Grandfather | ||||
Maternal Uncle 1: | ||||
Paternal Aunt 1: | ||||
Paternal Uncle 1: | ||||
Maternal Cousin 1: | ||||
Maternal Cousin 2: | ||||
Maternal Cousin 3: | ||||
Paternal Cousin 1: | ||||
Paternal Cousin 2: | ||||
Paternal Cousin 3: | ||||
Paternal Cousin 4: | ||||
Paternal Cousin 5: |
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: | ||||
Maternal Grandmother | ||||
Maternal Grandfather | ||||
Paternal Grandmother | ||||
Paternal Grandfather | ||||
Maternal Uncle 1: | ||||
Paternal Aunt 1: | ||||
Paternal Uncle 1: | ||||
Maternal Cousin 1: | ||||
Maternal Cousin 2: | ||||
Maternal Cousin 3: | ||||
Paternal Cousin 1: | ||||
Paternal Cousin 2: | ||||
Paternal Cousin 3: | ||||
Paternal Cousin 4: | ||||
Paternal Cousin 5: |
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: | ||||
Maternal Grandmother | ||||
Maternal Grandfather | ||||
Paternal Grandmother | ||||
Paternal Grandfather | ||||
Maternal Uncle 1: | ||||
Paternal Aunt 1: | ||||
Paternal Uncle 1: | ||||
Maternal Cousin 1: | ||||
Maternal Cousin 2: | ||||
Maternal Cousin 3: | ||||
Paternal Cousin 1: | ||||
Paternal Cousin 2: | ||||
Paternal Cousin 3: | ||||
Paternal Cousin 4: | ||||
Paternal Cousin 5: |
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: | ||||
Maternal Grandmother | ||||
Maternal Grandfather | ||||
Paternal Grandmother | ||||
Paternal Grandfather | ||||
Maternal Uncle 1: | ||||
Paternal Aunt 1: | ||||
Paternal Uncle 1: | ||||
Maternal Cousin 1: | ||||
Maternal Cousin 2: | ||||
Maternal Cousin 3: | ||||
Paternal Cousin 1: | ||||
Paternal Cousin 2: | ||||
Paternal Cousin 3: | ||||
Paternal Cousin 4: | ||||
Paternal Cousin 5: |
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 | |||
Maternal Grandmother | ||||
Maternal Grandfather | ||||
Paternal Grandmother | ||||
Paternal Grandfather | ||||
Maternal Uncle 1: | ||||
Paternal Aunt 1: | ||||
Paternal Uncle 1: | ||||
Maternal Cousin 1: | ||||
Maternal Cousin 2: | ||||
Maternal Cousin 3: | ||||
Paternal Cousin 1: | ||||
Paternal Cousin 2: | ||||
Paternal Cousin 3: | ||||
Paternal Cousin 4: | ||||
Paternal Cousin 5: |
Relative | Cancer of the Uterus (age of onset) |
Varicocele | Other Genital/Reproductive Disorder (age of onset & disorder) |
---|---|---|---|
Self | |||
Mother | |||
Father | |||
Brother 1: | |||
Sister 1: | |||
Maternal Grandmother | |||
Maternal Grandfather | |||
Paternal Grandmother | |||
Paternal Grandfather | |||
Maternal Uncle 1: | |||
Paternal Aunt 1: | |||
Paternal Uncle 1: | |||
Maternal Cousin 1: | |||
Maternal Cousin 2: | |||
Maternal Cousin 3: | |||
Paternal Cousin 1: | |||
Paternal Cousin 2: | |||
Paternal Cousin 3: | |||
Paternal Cousin 4: | |||
Paternal Cousin 5: |
Relative | Acne (age of onset) |
Scarring Acne (age of onset) |
Eczema (age of onset) |
Psoriasis (age of onset) |
---|---|---|---|---|
Self | ||||
Mother | ||||
Father | ||||
Brother 1: | ||||
Sister 1: | ||||
Maternal Grandmother | ||||
Maternal Grandfather | ||||
Paternal Grandmother | ||||
Paternal Grandfather | ||||
Maternal Uncle 1: | ||||
Paternal Aunt 1: | ||||
Paternal Uncle 1: | ||||
Maternal Cousin 1: | ||||
Maternal Cousin 2: | ||||
Maternal Cousin 3: | ||||
Paternal Cousin 1: | ||||
Paternal Cousin 2: | ||||
Paternal Cousin 3: | ||||
Paternal Cousin 4: | ||||
Paternal Cousin 5: |
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: | |||
Maternal Grandmother | |||
Maternal Grandfather | |||
Paternal Grandmother | |||
Paternal Grandfather | |||
Maternal Uncle 1: | |||
Paternal Aunt 1: | |||
Paternal Uncle 1: | |||
Maternal Cousin 1: | |||
Maternal Cousin 2: | |||
Maternal Cousin 3: | |||
Paternal Cousin 1: | |||
Paternal Cousin 2: | |||
Paternal Cousin 3: | |||
Paternal Cousin 4: | |||
Paternal Cousin 5: |
Relative | Migraines (age of onset) |
Mental Retardation (age of onset) |
Alzheimers (age of onset) |
Multiple Sclerosis (age of onset) |
---|---|---|---|---|
Self | 10 | |||
Mother | 10 | |||
Father | ||||
Brother 1: | 10 | |||
Sister 1: | 10 | |||
Maternal Grandmother | ||||
Maternal Grandfather | ||||
Paternal Grandmother | ||||
Paternal Grandfather | ||||
Maternal Uncle 1: | ||||
Paternal Aunt 1: | ||||
Paternal Uncle 1: | ||||
Maternal Cousin 1: | ||||
Maternal Cousin 2: | ||||
Maternal Cousin 3: | ||||
Paternal Cousin 1: | ||||
Paternal Cousin 2: | ||||
Paternal Cousin 3: | ||||
Paternal Cousin 4: | ||||
Paternal Cousin 5: |
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: | ||||
Maternal Grandmother | ||||
Maternal Grandfather | ||||
Paternal Grandmother | ||||
Paternal Grandfather | ||||
Maternal Uncle 1: | ||||
Paternal Aunt 1: | ||||
Paternal Uncle 1: | ||||
Maternal Cousin 1: | ||||
Maternal Cousin 2: | ||||
Maternal Cousin 3: | ||||
Paternal Cousin 1: | ||||
Paternal Cousin 2: | ||||
Paternal Cousin 3: | ||||
Paternal Cousin 4: | ||||
Paternal Cousin 5: |
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: | ||||
Maternal Grandmother | ||||
Maternal Grandfather | ||||
Paternal Grandmother | ||||
Paternal Grandfather | ||||
Maternal Uncle 1: | ||||
Paternal Aunt 1: | ||||
Paternal Uncle 1: | ||||
Maternal Cousin 1: | ||||
Maternal Cousin 2: | ||||
Maternal Cousin 3: | ||||
Paternal Cousin 1: | ||||
Paternal Cousin 2: | ||||
Paternal Cousin 3: | ||||
Paternal Cousin 4: | ||||
Paternal Cousin 5: |
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: | ||||
Maternal Grandmother | ||||
Maternal Grandfather | ||||
Paternal Grandmother | ||||
Paternal Grandfather | ||||
Maternal Uncle 1: | ||||
Paternal Aunt 1: | ||||
Paternal Uncle 1: | ||||
Maternal Cousin 1: | ||||
Maternal Cousin 2: | ||||
Maternal Cousin 3: | ||||
Paternal Cousin 1: | ||||
Paternal Cousin 2: | ||||
Paternal Cousin 3: | ||||
Paternal Cousin 4: | ||||
Paternal Cousin 5: |
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: | ||||
Maternal Grandmother | ||||
Maternal Grandfather | ||||
Paternal Grandmother | ||||
Paternal Grandfather | ||||
Maternal Uncle 1: | ||||
Paternal Aunt 1: | ||||
Paternal Uncle 1: | ||||
Maternal Cousin 1: | ||||
Maternal Cousin 2: | ||||
Maternal Cousin 3: | ||||
Paternal Cousin 1: | ||||
Paternal Cousin 2: | ||||
Paternal Cousin 3: | ||||
Paternal Cousin 4: | ||||
Paternal Cousin 5: |
Relative | Osteoporosis (age of onset) |
Dwarfism (age of onset) |
Arthritis (age of onset) |
Gout (age of onset) |
---|---|---|---|---|
Self |
|
|||
Mother |
|
|||
Father |
|
|||
Brother 1: |
|
|||
Sister 1: |
|
|||
Maternal Grandmother |
50s |
|||
Maternal Grandfather |
|
|||
Paternal Grandmother |
|
|||
Paternal Grandfather |
|
|||
Maternal Uncle 1: |
|
|||
Paternal Aunt 1: |
|
|||
Paternal Uncle 1: |
|
|||
Maternal Cousin 1: |
|
|||
Maternal Cousin 2: |
|
|||
Maternal Cousin 3: |
|
|||
Paternal Cousin 1: |
|
|||
Paternal Cousin 2: |
|
|||
Paternal Cousin 3: |
|
|||
Paternal Cousin 4: |
|
|||
Paternal Cousin 5: |
|
Relative | Myasthenia Gravis (age of onset) |
Other Muscle/Bone/Joint Disorder (age of onset & disorder) |
---|---|---|
Self | ||
Mother | ||
Father | ||
Brother 1: | ||
Sister 1: | ||
Maternal Grandmother | ||
Maternal Grandfather | ||
Paternal Grandmother | ||
Paternal Grandfather | ||
Maternal Uncle 1: | ||
Paternal Aunt 1: | ||
Paternal Uncle 1: | ||
Maternal Cousin 1: | ||
Maternal Cousin 2: | ||
Maternal Cousin 3: | ||
Paternal Cousin 1: | ||
Paternal Cousin 2: | ||
Paternal Cousin 3: | ||
Paternal Cousin 4: | ||
Paternal Cousin 5: |
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: | ||||
Maternal Grandmother | ||||
Maternal Grandfather | ||||
Paternal Grandmother | ||||
Paternal Grandfather | ||||
Maternal Uncle 1: | ||||
Paternal Aunt 1: | ||||
Paternal Uncle 1: | ||||
Maternal Cousin 1: | ||||
Maternal Cousin 2: | ||||
Maternal Cousin 3: | ||||
Paternal Cousin 1: | ||||
Paternal Cousin 2: | ||||
Paternal Cousin 3: | ||||
Paternal Cousin 4: | ||||
Paternal Cousin 5: |
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: | ||||
Maternal Grandmother | ||||
Maternal Grandfather | ||||
Paternal Grandmother | ||||
Paternal Grandfather | ||||
Maternal Uncle 1: | ||||
Paternal Aunt 1: | ||||
Paternal Uncle 1: | ||||
Maternal Cousin 1: | ||||
Maternal Cousin 2: | ||||
Maternal Cousin 3: | ||||
Paternal Cousin 1: | ||||
Paternal Cousin 2: | ||||
Paternal Cousin 3: | ||||
Paternal Cousin 4: | ||||
Paternal Cousin 5: |
Relative | Other Sight/Hearing/Olfactory Disorder (age of onset & disorder) |
---|---|
Self | |
Mother | |
Father | |
Brother 1: | |
Sister 1: | |
Maternal Grandmother | |
Maternal Grandfather | |
Paternal Grandmother | |
Paternal Grandfather | |
Maternal Uncle 1: | |
Paternal Aunt 1: | |
Paternal Uncle 1: | |
Maternal Cousin 1: | |
Maternal Cousin 2: | |
Maternal Cousin 3: | |
Paternal Cousin 1: | |
Paternal Cousin 2: | |
Paternal Cousin 3: | |
Paternal Cousin 4: | |
Paternal Cousin 5: |
Relative | Alcoholism (age of onset) |
Drug Abuse or Addiction (age of onset) |
Smoker/Tobacco Use (age of onset) |
---|---|---|---|
Self | |||
Mother | |||
Father | |||
Brother 1: | |||
Sister 1: | |||
Maternal Grandmother | 30s | ||
Maternal Grandfather | |||
Paternal Grandmother | |||
Paternal Grandfather | |||
Maternal Uncle 1: | |||
Paternal Aunt 1: | |||
Paternal Uncle 1: | |||
Maternal Cousin 1: | |||
Maternal Cousin 2: | |||
Maternal Cousin 3: | |||
Paternal Cousin 1: | |||
Paternal Cousin 2: | |||
Paternal Cousin 3: | |||
Paternal Cousin 4: | |||
Paternal Cousin 5: |
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: | ||||
Maternal Grandmother | ||||
Maternal Grandfather | ||||
Paternal Grandmother | ||||
Paternal Grandfather | ||||
Maternal Uncle 1: | ||||
Paternal Aunt 1: | ||||
Paternal Uncle 1: | ||||
Maternal Cousin 1: | ||||
Maternal Cousin 2: | ||||
Maternal Cousin 3: | ||||
Paternal Cousin 1: | ||||
Paternal Cousin 2: | ||||
Paternal Cousin 3: | ||||
Paternal Cousin 4: | ||||
Paternal Cousin 5: |