Donor Number 603

General Information

Donor Code:

603

Ethnic Origin:

Italian, Norwegian, Scotch-Irish, Swedish

Blood Type:

A Positive

Hair Color:

Blond

Type of Hair:

Straight

Thickness of Hair:

Average

Age at Time of Retrieval:

Eye Color:

Green

Complexion Relative to Race:

Fair

Bone Structure:

Medium

Height:

5'10"

Weight:

160

Handedness:

Right-Handed

Interests

Swimming, boating, fishing, camping, snow skiing, snowmobiling, drawing, painting, making pottery and keeping up with her son.

Education

Education Status: High School Diploma Obtained

Area of Study: Nursing

General Health

Vision: Excellent, does not wear lenses

Hearing: Excellent

Dentition: Good, 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: Alive and in his 70's, Prostate cancer in his 70s

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

Maternal Grandfather: Alive and in his 70's, Prostate cancer in his 70s

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

Father: Died in his 30's, Died in a hunting accident

Mother: Alive and in her 50's, Healthy, occasional migraine headache

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 11/8/2012.

UPDATED HEALTH HISTORY:

No new information reported at this time.

Donation and Fertility

Donor Communication (Type): Open

Limited Available? No

Past Pregnancy: No

Staff Impressions

Face: Tapered oval shape with high cheekbones

Lips: Medium fullness to upper and lower lips

Nose: Slightly larger than normal, average shape and straight profile

Ears: Average size, tucked back, attached lobes

Eyes: Almond shape, straight on face, slightly smaller than average, deep set

Eyebrows: Medium fullness, curved

Summary: She is such a sweet girl, a bit shy when you first meet her with a smile to warm your heart. She is a hard worker, often working overtime to help at work. She will no doubt make a great nurse someday!

Donor Writing Sample/Essay

Childhood Photos

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Childhood Photos

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Expanded Profile

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, this simply means that it was a new question that was not asked at the time that particular donor completed her application form. Consequently, we are unable to provide a response for that question.

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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
Brother 1:
Brother 2:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Paternal Aunt 1:
Paternal Aunt 2:
Paternal Uncle 1:
Paternal Uncle 2:
Paternal Uncle 3:
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
Mother
Father
Brother 1:
Brother 2:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Paternal Aunt 1:
Paternal Aunt 2:
Paternal Uncle 1:
Paternal Uncle 2:
Paternal Uncle 3:
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
Brother 1:
Brother 2:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Paternal Aunt 1:
Paternal Aunt 2:
Paternal Uncle 1:
Paternal Uncle 2:
Paternal Uncle 3:
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
Father
Brother 1:
Brother 2:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Paternal Aunt 1:
Paternal Aunt 2:
Paternal Uncle 1:
Paternal Uncle 2:
Paternal Uncle 3:
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
Brother 1:
Brother 2:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Paternal Aunt 1:
Paternal Aunt 2:
Paternal Uncle 1:
Paternal Uncle 2:
Paternal Uncle 3:
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
Brother 1:
Brother 2:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Paternal Aunt 1:
Paternal Aunt 2:
Paternal Uncle 1:
Paternal Uncle 2:
Paternal Uncle 3:
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
Brother 1:
Brother 2:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Paternal Aunt 1:
Paternal Aunt 2:
Paternal Uncle 1:
Paternal Uncle 2:
Paternal Uncle 3:
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
Brother 1:
Brother 2:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Paternal Aunt 1:
Paternal Aunt 2:
Paternal Uncle 1:
Paternal Uncle 2:
Paternal Uncle 3:
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
Brother 1:
Brother 2:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Paternal Aunt 1:
Paternal Aunt 2:
Paternal Uncle 1:
Paternal Uncle 2:
Paternal Uncle 3:
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
Brother 1:
Brother 2:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Paternal Aunt 1:
Paternal Aunt 2:
Paternal Uncle 1:
Paternal Uncle 2:
Paternal Uncle 3:
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
Brother 1:
Brother 2:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Paternal Aunt 1:
Paternal Aunt 2:
Paternal Uncle 1:
Paternal Uncle 2:
Paternal Uncle 3:
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
Brother 1:
Brother 2:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Paternal Aunt 1:
Paternal Aunt 2:
Paternal Uncle 1:
Paternal Uncle 2:
Paternal Uncle 3:
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
Brother 1:
Brother 2:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Paternal Aunt 1:
Paternal Aunt 2:
Paternal Uncle 1:
Paternal Uncle 2:
Paternal Uncle 3:
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
Brother 1:
Brother 2:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Paternal Aunt 1:
Paternal Aunt 2:
Paternal Uncle 1:
Paternal Uncle 2:
Paternal Uncle 3:
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
Brother 1:
Brother 2:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Paternal Aunt 1:
Paternal Aunt 2:
Paternal Uncle 1:
Paternal Uncle 2:
Paternal Uncle 3:
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
Brother 1:
Brother 2:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Paternal Aunt 1:
Paternal Aunt 2:
Paternal Uncle 1:
Paternal Uncle 2:
Paternal Uncle 3:
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
Brother 1:
Brother 2:
Maternal Grandmother
Maternal Grandfather	70's
Paternal Grandmother
Paternal Grandfather	70's
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Paternal Aunt 1:
Paternal Aunt 2:
Paternal Uncle 1:
Paternal Uncle 2:
Paternal Uncle 3:
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
Brother 1:
Brother 2:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Paternal Aunt 1:
Paternal Aunt 2:
Paternal Uncle 1:
Paternal Uncle 2:
Paternal Uncle 3:
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
Father
Brother 1:
Brother 2:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Paternal Aunt 1:
Paternal Aunt 2:
Paternal Uncle 1:
Paternal Uncle 2:
Paternal Uncle 3:
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 (cont.)

Relative	Skin Cancer (age of onset)	Pigmentation Disorders (age of onset)	Other Skin Disorder (age of onset & disorder)
Self
Mother
Father
Brother 1:
Brother 2:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Paternal Aunt 1:
Paternal Aunt 2:
Paternal Uncle 1:
Paternal Uncle 2:
Paternal Uncle 3:
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	Teens
Mother	Teens
Father
Brother 1:
Brother 2:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Paternal Aunt 1:
Paternal Aunt 2:
Paternal Uncle 1:
Paternal Uncle 2:
Paternal Uncle 3:
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
Brother 1:
Brother 2:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Paternal Aunt 1:
Paternal Aunt 2:
Paternal Uncle 1:
Paternal Uncle 2:
Paternal Uncle 3:
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
Brother 1:
Brother 2:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Paternal Aunt 1:
Paternal Aunt 2:
Paternal Uncle 1:
Paternal Uncle 2:
Paternal Uncle 3:
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
Brother 1:
Brother 2:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Paternal Aunt 1:
Paternal Aunt 2:
Paternal Uncle 1:
Paternal Uncle 2:
Paternal Uncle 3:
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
Brother 1:
Brother 2:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Paternal Aunt 1:
Paternal Aunt 2:
Paternal Uncle 1:
Paternal Uncle 2:
Paternal Uncle 3:
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
Brother 1:
Brother 2:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Paternal Aunt 1:
Paternal Aunt 2:
Paternal Uncle 1:
Paternal Uncle 2:
Paternal Uncle 3:
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
Brother 1:
Brother 2:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Paternal Aunt 1:
Paternal Aunt 2:
Paternal Uncle 1:
Paternal Uncle 2:
Paternal Uncle 3:
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
Brother 1:
Brother 2:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Paternal Aunt 1:
Paternal Aunt 2:
Paternal Uncle 1:
Paternal Uncle 2:
Paternal Uncle 3:
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			Teens
Mother
Father
Brother 1:
Brother 2:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Paternal Aunt 1:
Paternal Aunt 2:
Paternal Uncle 1:
Paternal Uncle 2:
Paternal Uncle 3:
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
Brother 1:
Brother 2:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Paternal Aunt 1:
Paternal Aunt 2:
Paternal Uncle 1:
Paternal Uncle 2:
Paternal Uncle 3:
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
Brother 1:
Brother 2:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Paternal Aunt 1:
Paternal Aunt 2:
Paternal Uncle 1:
Paternal Uncle 2:
Paternal Uncle 3:
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 (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
Brother 1:
Brother 2:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Paternal Aunt 1:
Paternal Aunt 2:
Paternal Uncle 1:
Paternal Uncle 2:
Paternal Uncle 3:
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: