Donor Number 3827

Inventory

Donor Number: 3827

This donor is currently donating ?

Our apologies. You've selected one of our most popular donors. This donor's stock is currently in quarantine. Would you like to be notified when this donor is out of quarantine?

Sign up for Donor Notifications

Inventory lists are based on daily inventory counts. The listing does not include orders in progress. Orders will be filled on a first come, first serve basis and inventories may shift as orders process.

Enter the Purchase Center

General Information

Donor Code:

3827

Ethnic Origin:

French, German, Irish

Blood Type:

A Positive

Hair Color:

Brown

Type of Hair:

Wavy

Thickness of Hair:

Thick

Eye Color:

Hazel

Complexion Relative to Race:

Medium

Bone Structure:

Medium

Height:

5'11"

Weight:

155

Handedness:

Left-Handed

Interests

He enjoys paintball, video games, whitewater rafting, fishing boating, reading, and spending time with family and friends.

Education

Education Status: Undergraduate Student

Area of Study: Business Administration, Economics, Finance

General Health

CMV Status (All donors test CMV-IgM Negative): Positive

Vision: Poor, does wear lenses

Hearing: Excellent

Dentition: Excellent, orthodontia required

Allergies: None known

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.

Family Health

Paternal Grandfather: Died in his 70's, lung cancer in his 60s, smoker

Paternal Grandmother: Alive and in her 80's, Healthy, type II diabetes, lifestyle related, smoker, osteoarthritis

Maternal Grandfather: Alive and in his 80's, Heart Attack in his 80s, type II diabetes, lifestyle related

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

Father: Alive and in his 60's, Healthy, type II diabetes, lifestyle related, smoker, osteoarthritis

Mother: Alive and in her 50's, Healthy, type II diabetes, lifestyle related

Siblings: One sister with Antiphospholipid Syndrome, she also has melanoma due to excessive use of tanning beds, his other sister died in an accident.

Genetic Screening Performed: Yes

This donor has been screened for more than 100 genetic diseases (via targeted mutation analysis) and has been found to test positive for the following:

NEGATIVE for all disease tested

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 7/7/2012.

UPDATED HEALTH HISTORY:

No new information reported at this time.

Donation and Fertility

Donor Communication (Type): Anonymous

Limited Available? Limited product available (12 vials or less)

Quarantine: All remaining vials are currently in quarantine. Please email our office for next estimated release date

Past Pregnancy: Yes

Staff Impressions

Face: Oval shape

Lips: Thin upper lip, full lower lip

Nose: Average size, somewhat narrow, very slight bump seen on his profile

Ears: Average size, tucked back, attached lobes

Eyes: Almond shape, straight on face, deep set

Eyebrows: Thick and straight

Summary: He is a quiet young man, sometimes difficult to get to smile. He is curious, intelligent and well-spoken.

Donor Writing Sample/Essay

Childhood Photos

Price: $25

Some of our donors have agreed to provide photos in their childhood years. You may find 1-6 photosof the donor depending on the photos provided. Once purchased, the photos are available for viewing from your account. Per the stipulation of the donor, the photos are viewable, but not reproducible.

If you are purchasing photos in anticipation of purchasing donor eggs, please call to check inventory prior to purchase. Although rare, it is possible to purchase a donor photo and then find that the donor no longer has eggs available. As donor inventory is very dynamic, we are unable to offer refunds on photos because of donor inventory shortages.

Purchase Childhood Photo

Childhood Photos

Purchase

Expanded Profile

Price: $25

Information contained in our expanded donor profiles has changed over time and consequently, not every question asked today was asked in previous years. When you see an answer to a question that is N/A, please understand that this was simply a new question that was not asked at the time that particular donor completed his/her application form, and consequently, we are unable to provide a response for that question.

If you are purchasing an expanded profile for a donor listed as "available on-line", the profile will be viewable from your account once we have processed your credit card which is typically 1 business day from the day you place the order. For expanded profiles listed as "available by mail", you can expect to receive those within 3 business days of placing your order.

This donor's expanded profile is available Online.

Purchase Expanded Profile

Note: Expanded profiles take some time to load. Thank you for your patience.

Expanded Profile

Purchase

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:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Uncle 1:
Maternal Uncle 2:
Maternal Uncle 3:
Paternal Aunt 1:
Paternal Aunt 2:
Maternal Cousin 1:
Maternal Cousin 2:
Maternal Cousin 3:
Maternal Cousin 4:
Maternal Cousin 5:
Maternal Cousin 6:
Paternal Cousin 1:
Paternal Cousin 2:

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

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

Relative	Problem at birth: Breathing, respiratory system	Problem at birth: Heart	Problem at birth: Other organs	Problem at birth: Genital, urinary, reproductive
Self	Partially collapsed lung. Does not appear to be genetic in nature.
Mother
Father
Sister 1:
Sister 2:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Uncle 1:
Maternal Uncle 2:
Maternal Uncle 3:
Paternal Aunt 1:
Paternal Aunt 2:
Maternal Cousin 1:
Maternal Cousin 2:
Maternal Cousin 3:
Maternal Cousin 4:
Maternal Cousin 5:
Maternal Cousin 6:
Paternal Cousin 1:
Paternal Cousin 2:

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

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

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

Medical History: Heart/Vascular

Relative	Heart Attack (age of onset)	High Blood Pressure (age of onset)
Self
Mother		50's
Father		50's
Sister 1:
Sister 2:
Maternal Grandmother
Maternal Grandfather	80's	70's
Paternal Grandmother		60's
Paternal Grandfather
Maternal Aunt 1:
Maternal Uncle 1:
Maternal Uncle 2:
Maternal Uncle 3:
Paternal Aunt 1:
Paternal Aunt 2:
Maternal Cousin 1:
Maternal Cousin 2:
Maternal Cousin 3:
Maternal Cousin 4:
Maternal Cousin 5:
Maternal Cousin 6:
Paternal Cousin 1:
Paternal Cousin 2:

Medical History: Heart/Vascular (cont.)

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

Medical History: Blood

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

Medical History: Blood (cont.)

Relative	Immune Problems (age of onset)	Other Blood Disorder (age of onset & disorder)
Self
Mother
Father
Sister 1:		20's Antiphospholipid Syndrome
Sister 2:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Uncle 1:
Maternal Uncle 2:
Maternal Uncle 3:
Paternal Aunt 1:
Paternal Aunt 2:
Maternal Cousin 1:
Maternal Cousin 2:
Maternal Cousin 3:
Maternal Cousin 4:
Maternal Cousin 5:
Maternal Cousin 6:
Paternal Cousin 1:
Paternal Cousin 2:

Medical History: Respiratory

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

Medical History: Respiratory (cont.)

Relative	Lung Cancer (age of onset)	Pneumonia (age of onset)	Other Respiratory Disorder (age of onset & disorder)
Self
Mother
Father
Sister 1:
Sister 2:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather	60's
Maternal Aunt 1:
Maternal Uncle 1:
Maternal Uncle 2:
Maternal Uncle 3:
Paternal Aunt 1:
Paternal Aunt 2:
Maternal Cousin 1:
Maternal Cousin 2:
Maternal Cousin 3:
Maternal Cousin 4:
Maternal Cousin 5:
Maternal Cousin 6:
Paternal Cousin 1:
Paternal Cousin 2:

Medical History: Gastro-Intestinal

Relative	Ulcers (age of onset)	Gall Stones (age of onset)	Hepatitis A (age of onset)	Hepatitis B (age of onset)
Self
Mother
Father		50's
Sister 1:
Sister 2:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Uncle 1:
Maternal Uncle 2:
Maternal Uncle 3:
Paternal Aunt 1:
Paternal Aunt 2:
Maternal Cousin 1:
Maternal Cousin 2:
Maternal Cousin 3:
Maternal Cousin 4:
Maternal Cousin 5:
Maternal Cousin 6:
Paternal Cousin 1:
Paternal Cousin 2:

Medical History: Gastro-Intestinal (cont.)

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

Medical History: Gastro-Intestinal (cont.)

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

Medical History: Metabolic/Endocrine

Relative	Diabetes (age of onset)	Hypoglycemia (age of onset)	Thyroid Cancer (age of onset)	Thyroid Disease (age of onset)
Self
Mother	50's
Father	50's
Sister 1:
Sister 2:
Maternal Grandmother
Maternal Grandfather	60's
Paternal Grandmother	60's
Paternal Grandfather
Maternal Aunt 1:
Maternal Uncle 1:
Maternal Uncle 2:
Maternal Uncle 3:
Paternal Aunt 1:
Paternal Aunt 2:
Maternal Cousin 1:
Maternal Cousin 2:
Maternal Cousin 3:
Maternal Cousin 4:
Maternal Cousin 5:
Maternal Cousin 6:
Paternal Cousin 1:
Paternal Cousin 2:

Medical History: Metabolic/Endocrine (cont.)

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

Medical History: Urinary

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

Medical History: Genital/Reproductive

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

Medical History: Genital/Reproductive (cont.)

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

Medical History: Genital/Reproductive (cont.)

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

Medical History: Skin

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

Medical History: Skin (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:	30's
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Uncle 1:
Maternal Uncle 2:
Maternal Uncle 3:
Paternal Aunt 1:
Paternal Aunt 2:
Maternal Cousin 1:
Maternal Cousin 2:
Maternal Cousin 3:
Maternal Cousin 4:
Maternal Cousin 5:
Maternal Cousin 6:
Paternal Cousin 1:
Paternal Cousin 2:

Medical History: Neurological

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

Medical History: Neurological (cont.)

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

Medical History: Neurological (cont.)

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

Medical History: Mental Health

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

Medical History: Muscles/Bones/Joints

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

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

Relative	Osteoporosis (age of onset)	Dwarfism (age of onset)	Arthritis (age of onset)	Gout (age of onset)
Self
Mother
Father			50's
Sister 1:
Sister 2:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather			60's
Maternal Aunt 1:
Maternal Uncle 1:
Maternal Uncle 2:
Maternal Uncle 3:
Paternal Aunt 1:
Paternal Aunt 2:
Maternal Cousin 1:
Maternal Cousin 2:
Maternal Cousin 3:
Maternal Cousin 4:
Maternal Cousin 5:
Maternal Cousin 6:
Paternal Cousin 1:
Paternal Cousin 2:

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

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

Medical History: Sight/Hearing/Olfactory

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

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

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

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

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

Medical History: Other

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

Medical History: Other (cont.)

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