Donor Number 753

General Information

Donor Code:
753
Ethnic Origin:
German, Irish, Polish, Russian
Blood Type:
B Positive
Hair Color:
Dark Brown
Type of Hair:
Wavy
Thickness of Hair:
Thick
Age at Time of Retrieval:
28
Eye Color:
Blue
Complexion Relative to Race:
Fair
Bone Structure:
Petite
Height:
5'1"
Weight:
118
Handedness:
Right-Handed

In her free time, she loves to read mystery novels. She previously was very active theatre performances, so she loves to watch productions and visit museums.

Education Status: Vocational Degree/Certificate Obtained

Area of Study: Sociology, Theatre

Vision: Poor, does wear lenses

Hearing: Excellent

Dentition: Excellent, orthodontia required

Allergies: Morphine

Hospitalization: 2010s

Alcohol Usage: Does not drink alcohol

Tobacco Usage: Does not smoke

Drug Usage: Tests NEGATIVE for Drugs of Abuse.

Paternal Grandfather: Died in his 80's, Alcoholism in his 40's

Paternal Grandmother: Died in her 80's, Natural causes

Maternal Grandfather: Died in his 90's, Stroke in his 80's

Maternal Grandmother: Died in her 80's, Alzheimer's and Pheumonia in her 80's

Father: Alive and in his 70's, Skin cancer in his 60's due to prolonged sun exposure, heart attack in his 60's, Dementia in his 70's

Mother: Alive and in her 60's, Healthy

Siblings: At least one sibling, 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: Metachromatic Leukodystrophy (carrier) MTHFR Deficiency (mild condition) 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. Before excluding this donor due to their genetic testing results, please call our Contracted Genetics Dept. (through California Cryobank) at 877-743-6384, M-F 8:00am - 5:00pm PST for more information

Donor Communication (Type): Open

Limited Available? Fewer than 6 eggs available

Past Pregnancy: Yes

Face: Round shape with average forehead set, 1 small mole

Lips: Thin upper lip, medium fullness to lower lip

Nose: Round shape, average width and length, straight on profile

Ears: Small ears with attached lobes

Eyes: Round shape, medium sized eyes, average set.

Eyebrows: Medium fullness, slightly curved

Summary: She is such a joy to visit with. She is very intellectual, organized, and loves to spend time with her daughter.

 

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
Brother 1:
Sister 1:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Uncle 1:
Paternal Aunt 1:
Paternal Aunt 2:
Paternal Aunt 3:
Paternal Aunt 4:
Paternal Aunt 5:
Paternal Aunt 6:
Paternal Aunt 7:
Paternal Uncle 1:
Paternal Uncle 2:
Paternal Uncle 3:
Maternal Cousin 1:
Maternal Cousin 2:
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:

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:
Sister 1:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Uncle 1:
Paternal Aunt 1:
Paternal Aunt 2:
Paternal Aunt 3:
Paternal Aunt 4:
Paternal Aunt 5:
Paternal Aunt 6:
Paternal Aunt 7:
Paternal Uncle 1:
Paternal Uncle 2:
Paternal Uncle 3:
Maternal Cousin 1:
Maternal Cousin 2:
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:

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:
Sister 1:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Uncle 1:
Paternal Aunt 1:
Paternal Aunt 2:
Paternal Aunt 3:
Paternal Aunt 4:
Paternal Aunt 5:
Paternal Aunt 6:
Paternal Aunt 7:
Paternal Uncle 1:
Paternal Uncle 2:
Paternal Uncle 3:
Maternal Cousin 1:
Maternal Cousin 2:
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:

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 60's 60's
Brother 1:
Sister 1:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Uncle 1:
Paternal Aunt 1:
Paternal Aunt 2:
Paternal Aunt 3:
Paternal Aunt 4:
Paternal Aunt 5:
Paternal Aunt 6:
Paternal Aunt 7:
Paternal Uncle 1:
Paternal Uncle 2:
Paternal Uncle 3:
Maternal Cousin 1:
Maternal Cousin 2:
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:

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:
Sister 1:
Maternal Grandmother
Maternal Grandfather 80's
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Uncle 1:
Paternal Aunt 1:
Paternal Aunt 2:
Paternal Aunt 3:
Paternal Aunt 4:
Paternal Aunt 5:
Paternal Aunt 6:
Paternal Aunt 7:
Paternal Uncle 1:
Paternal Uncle 2:
Paternal Uncle 3:
Maternal Cousin 1:
Maternal Cousin 2:
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:

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:
Sister 1:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Uncle 1:
Paternal Aunt 1:
Paternal Aunt 2:
Paternal Aunt 3:
Paternal Aunt 4:
Paternal Aunt 5:
Paternal Aunt 6:
Paternal Aunt 7:
Paternal Uncle 1:
Paternal Uncle 2:
Paternal Uncle 3:
Maternal Cousin 1:
Maternal Cousin 2:
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:

Medical History: Blood (cont.)

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 Aunt 1:
Maternal Uncle 1:
Paternal Aunt 1:
Paternal Aunt 2:
Paternal Aunt 3:
Paternal Aunt 4:
Paternal Aunt 5:
Paternal Aunt 6:
Paternal Aunt 7:
Paternal Uncle 1:
Paternal Uncle 2:
Paternal Uncle 3:
Maternal Cousin 1:
Maternal Cousin 2:
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:

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: Pre-Teens
Sister 1:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Uncle 1:
Paternal Aunt 1:
Paternal Aunt 2:
Paternal Aunt 3:
Paternal Aunt 4:
Paternal Aunt 5:
Paternal Aunt 6:
Paternal Aunt 7:
Paternal Uncle 1:
Paternal Uncle 2:
Paternal Uncle 3:
Maternal Cousin 1:
Maternal Cousin 2:
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:

Medical History: Respiratory (cont.)

Relative Lung Cancer
(age of onset)
Pneumonia
(age of onset)
Other Respiratory Disorder
(age of onset & disorder)
Self Teens
Mother
Father
Brother 1:
Sister 1:
Maternal Grandmother 80's
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Uncle 1:
Paternal Aunt 1:
Paternal Aunt 2:
Paternal Aunt 3:
Paternal Aunt 4:
Paternal Aunt 5:
Paternal Aunt 6:
Paternal Aunt 7:
Paternal Uncle 1:
Paternal Uncle 2:
Paternal Uncle 3:
Maternal Cousin 1:
Maternal Cousin 2:
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:

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:
Sister 1:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Uncle 1:
Paternal Aunt 1:
Paternal Aunt 2:
Paternal Aunt 3:
Paternal Aunt 4:
Paternal Aunt 5:
Paternal Aunt 6:
Paternal Aunt 7:
Paternal Uncle 1:
Paternal Uncle 2:
Paternal Uncle 3:
Maternal Cousin 1:
Maternal Cousin 2:
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:

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:
Sister 1:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Uncle 1:
Paternal Aunt 1:
Paternal Aunt 2:
Paternal Aunt 3:
Paternal Aunt 4:
Paternal Aunt 5:
Paternal Aunt 6:
Paternal Aunt 7:
Paternal Uncle 1:
Paternal Uncle 2:
Paternal Uncle 3:
Maternal Cousin 1:
Maternal Cousin 2:
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:

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:
Sister 1:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Uncle 1:
Paternal Aunt 1:
Paternal Aunt 2:
Paternal Aunt 3:
Paternal Aunt 4:
Paternal Aunt 5:
Paternal Aunt 6:
Paternal Aunt 7:
Paternal Uncle 1:
Paternal Uncle 2:
Paternal Uncle 3:
Maternal Cousin 1:
Maternal Cousin 2:
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:

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:
Sister 1:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Uncle 1:
Paternal Aunt 1:
Paternal Aunt 2:
Paternal Aunt 3:
Paternal Aunt 4:
Paternal Aunt 5:
Paternal Aunt 6:
Paternal Aunt 7:
Paternal Uncle 1:
Paternal Uncle 2:
Paternal Uncle 3:
Maternal Cousin 1:
Maternal Cousin 2:
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:

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:
Sister 1:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Uncle 1:
Paternal Aunt 1:
Paternal Aunt 2:
Paternal Aunt 3:
Paternal Aunt 4:
Paternal Aunt 5:
Paternal Aunt 6:
Paternal Aunt 7:
Paternal Uncle 1:
Paternal Uncle 2:
Paternal Uncle 3:
Maternal Cousin 1:
Maternal Cousin 2:
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:

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:
Sister 1:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Uncle 1:
Paternal Aunt 1:
Paternal Aunt 2:
Paternal Aunt 3:
Paternal Aunt 4:
Paternal Aunt 5:
Paternal Aunt 6:
Paternal Aunt 7:
Paternal Uncle 1:
Paternal Uncle 2:
Paternal Uncle 3:
Maternal Cousin 1:
Maternal Cousin 2:
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:

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:
Sister 1:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Uncle 1:
Paternal Aunt 1:
Paternal Aunt 2:
Paternal Aunt 3:
Paternal Aunt 4:
Paternal Aunt 5:
Paternal Aunt 6:
Paternal Aunt 7:
Paternal Uncle 1:
Paternal Uncle 2:
Paternal Uncle 3:
Maternal Cousin 1:
Maternal Cousin 2:
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:

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:
Sister 1:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Uncle 1:
Paternal Aunt 1:
Paternal Aunt 2:
Paternal Aunt 3:
Paternal Aunt 4:
Paternal Aunt 5:
Paternal Aunt 6:
Paternal Aunt 7:
Paternal Uncle 1:
Paternal Uncle 2:
Paternal Uncle 3:
Maternal Cousin 1:
Maternal Cousin 2:
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:

Medical History: Genital/Reproductive (cont.)

Relative Cancer of the Uterus
(age of onset)
Varicocele Other Genital/Reproductive Disorder
(age of onset & disorder)
Self 20's Adhesions formed around uterus
Mother
Father
Brother 1:
Sister 1:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Uncle 1:
Paternal Aunt 1:
Paternal Aunt 2:
Paternal Aunt 3:
Paternal Aunt 4:
Paternal Aunt 5:
Paternal Aunt 6:
Paternal Aunt 7:
Paternal Uncle 1:
Paternal Uncle 2:
Paternal Uncle 3:
Maternal Cousin 1:
Maternal Cousin 2:
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:

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
Brother 1:
Sister 1:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Uncle 1:
Paternal Aunt 1:
Paternal Aunt 2:
Paternal Aunt 3:
Paternal Aunt 4:
Paternal Aunt 5:
Paternal Aunt 6:
Paternal Aunt 7:
Paternal Uncle 1:
Paternal Uncle 2:
Paternal Uncle 3:
Maternal Cousin 1:
Maternal Cousin 2:
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:

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 60's
Brother 1:
Sister 1:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Uncle 1:
Paternal Aunt 1:
Paternal Aunt 2:
Paternal Aunt 3:
Paternal Aunt 4:
Paternal Aunt 5:
Paternal Aunt 6:
Paternal Aunt 7:
Paternal Uncle 1:
Paternal Uncle 2:
Paternal Uncle 3:
Maternal Cousin 1:
Maternal Cousin 2:
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:

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
Brother 1:
Sister 1:
Maternal Grandmother 80's
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Uncle 1:
Paternal Aunt 1:
Paternal Aunt 2:
Paternal Aunt 3:
Paternal Aunt 4:
Paternal Aunt 5:
Paternal Aunt 6:
Paternal Aunt 7:
Paternal Uncle 1:
Paternal Uncle 2:
Paternal Uncle 3:
Maternal Cousin 1:
Maternal Cousin 2:
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:

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:
Sister 1:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Uncle 1:
Paternal Aunt 1:
Paternal Aunt 2:
Paternal Aunt 3:
Paternal Aunt 4:
Paternal Aunt 5:
Paternal Aunt 6:
Paternal Aunt 7:
Paternal Uncle 1:
Paternal Uncle 2:
Paternal Uncle 3:
Maternal Cousin 1:
Maternal Cousin 2:
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:

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:
Sister 1:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Uncle 1:
Paternal Aunt 1:
Paternal Aunt 2:
Paternal Aunt 3:
Paternal Aunt 4:
Paternal Aunt 5:
Paternal Aunt 6:
Paternal Aunt 7:
Paternal Uncle 1:
Paternal Uncle 2:
Paternal Uncle 3:
Maternal Cousin 1:
Maternal Cousin 2:
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:

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:
Sister 1:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Uncle 1:
Paternal Aunt 1:
Paternal Aunt 2:
Paternal Aunt 3:
Paternal Aunt 4:
Paternal Aunt 5:
Paternal Aunt 6:
Paternal Aunt 7:
Paternal Uncle 1:
Paternal Uncle 2:
Paternal Uncle 3:
Maternal Cousin 1:
Maternal Cousin 2:
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:

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:
Sister 1:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Uncle 1:
Paternal Aunt 1:
Paternal Aunt 2:
Paternal Aunt 3:
Paternal Aunt 4:
Paternal Aunt 5:
Paternal Aunt 6:
Paternal Aunt 7:
Paternal Uncle 1:
Paternal Uncle 2:
Paternal Uncle 3:
Maternal Cousin 1:
Maternal Cousin 2:
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:

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:
Sister 1:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Uncle 1:
Paternal Aunt 1:
Paternal Aunt 2:
Paternal Aunt 3:
Paternal Aunt 4:
Paternal Aunt 5:
Paternal Aunt 6:
Paternal Aunt 7:
Paternal Uncle 1:
Paternal Uncle 2:
Paternal Uncle 3:
Maternal Cousin 1:
Maternal Cousin 2:
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:

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:
Sister 1:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Uncle 1:
Paternal Aunt 1:
Paternal Aunt 2:
Paternal Aunt 3:
Paternal Aunt 4:
Paternal Aunt 5:
Paternal Aunt 6:
Paternal Aunt 7:
Paternal Uncle 1:
Paternal Uncle 2:
Paternal Uncle 3:
Maternal Cousin 1:
Maternal Cousin 2:
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:

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:
Sister 1:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Uncle 1:
Paternal Aunt 1: 70's
Paternal Aunt 2:
Paternal Aunt 3:
Paternal Aunt 4:
Paternal Aunt 5:
Paternal Aunt 6:
Paternal Aunt 7:
Paternal Uncle 1:
Paternal Uncle 2:
Paternal Uncle 3:
Maternal Cousin 1:
Maternal Cousin 2:
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:

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
Brother 1:
Sister 1:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Uncle 1:
Paternal Aunt 1:
Paternal Aunt 2:
Paternal Aunt 3:
Paternal Aunt 4:
Paternal Aunt 5:
Paternal Aunt 6:
Paternal Aunt 7:
Paternal Uncle 1:
Paternal Uncle 2:
Paternal Uncle 3:
Maternal Cousin 1:
Maternal Cousin 2:
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:

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

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 Aunt 1:
Maternal Uncle 1:
Paternal Aunt 1:
Paternal Aunt 2:
Paternal Aunt 3:
Paternal Aunt 4:
Paternal Aunt 5:
Paternal Aunt 6:
Paternal Aunt 7:
Paternal Uncle 1:
Paternal Uncle 2:
Paternal Uncle 3:
Maternal Cousin 1:
Maternal Cousin 2:
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:

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: Teens Teens
Sister 1:
Maternal Grandmother
Maternal Grandfather 40's
Paternal Grandmother
Paternal Grandfather 40's
Maternal Aunt 1:
Maternal Uncle 1:
Paternal Aunt 1:
Paternal Aunt 2:
Paternal Aunt 3:
Paternal Aunt 4:
Paternal Aunt 5:
Paternal Aunt 6:
Paternal Aunt 7:
Paternal Uncle 1: 40's
Paternal Uncle 2: 40's
Paternal Uncle 3: 40's
Maternal Cousin 1:
Maternal Cousin 2:
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:

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 60's Skin
Brother 1:
Sister 1:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Uncle 1:
Paternal Aunt 1:
Paternal Aunt 2:
Paternal Aunt 3:
Paternal Aunt 4:
Paternal Aunt 5:
Paternal Aunt 6:
Paternal Aunt 7:
Paternal Uncle 1:
Paternal Uncle 2:
Paternal Uncle 3:
Maternal Cousin 1:
Maternal Cousin 2:
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: