Donor Number 522

General Information

Donor Code:
522
Ethnic Origin:
English, Hispanic, Mexican, Native American
Blood Type:
O Positive
Hair Color:
Light Brown
Type of Hair:
Curly
Thickness of Hair:
Thick
Age at Time of Retrieval:
21-24
Eye Color:
Brown
Complexion Relative to Race:
Medium
Bone Structure:
Medium
Height:
5'5"
Weight:
150
Handedness:
Ambidextrous

Reading (science fiction, classic and modern reads), swimming, running, dancing, puzzles, cooking, baking and training her dog

Education Status: Undergraduate Student

Area of Study: Biological Sciences, Biology

Vision: Good, does wear lenses

Hearing: Excellent

Dentition: Excellent, no orthodontia required

Allergies: Latex

Hospitalization: None known

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

Tobacco Usage: Does not smoke

Drug Usage: Tests NEGATIVE for Drugs of Abuse.

Paternal Grandfather: Died in his 90's, Heart attack

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

Maternal Grandfather: Alive and in his 80's, Liver disease from excessive alcohol

Maternal Grandmother: Died in her 60's, Lung cancer, emphysema, osteoporosis--smoker

Father: Died in his 40's, Car accident

Mother: Alive and in her 40's, Healthy

Siblings: All siblings are maternal half siblings and all are in good health. Two of her half brothers struggled with drug abuse in their early 20s

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. For any questions regarding the genetic testing results for this donor, 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: Oval shape

Lips: Thin upper lip, medium fullness to lower lip

Nose: Slightly larger than average, straight on profile, with a slight upturn at the end

Ears: Average size, tucked back, detached lobes

Eyes: Almond shape, average size, straight on face, beautiful deep brown color

Eyebrows: Thick and arched

Summary: What a treat to get to know her. She is definitely someone who knows in which direction she is headed. She plans to be a doctor and it is pretty clear that nothing will get in her way. She has a great smile, and shows it frequently.

 

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

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

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

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:
Sister 1:
Sister 2:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother 50's
Paternal Grandfather 90's
Maternal Aunt 1: 40's
Maternal Aunt 2:
Maternal Aunt 3:
Maternal Aunt 4:
Maternal Uncle 1:
Maternal Uncle 2:
Maternal Cousin 1:
Maternal Cousin 2:
Maternal Cousin 3:
Maternal Cousin 4:
Maternal Cousin 5:
Maternal Cousin 6:
Maternal Cousin 7:
Maternal Cousin 8:
Maternal Cousin 9:
Maternal Cousin 10:
Maternal Cousin 11:
Maternal Cousin 12:

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

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

Medical History: Blood (cont.)

Relative Immune Problems
(age of onset)
Other Blood Disorder
(age of onset & disorder)
Self
Mother
Father
Brother 1:
Brother 2:
Sister 1:
Sister 2:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Maternal Aunt 4:
Maternal Uncle 1:
Maternal Uncle 2:
Maternal Cousin 1:
Maternal Cousin 2:
Maternal Cousin 3:
Maternal Cousin 4:
Maternal Cousin 5:
Maternal Cousin 6:
Maternal Cousin 7:
Maternal Cousin 8:
Maternal Cousin 9:
Maternal Cousin 10:
Maternal Cousin 11:
Maternal Cousin 12:

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:
Sister 1:
Sister 2:
Maternal Grandmother 40's
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1: 20's Pre-Teens
Maternal Aunt 2:
Maternal Aunt 3:
Maternal Aunt 4:
Maternal Uncle 1:
Maternal Uncle 2:
Maternal Cousin 1:
Maternal Cousin 2:
Maternal Cousin 3:
Maternal Cousin 4:
Maternal Cousin 5:
Maternal Cousin 6:
Maternal Cousin 7:
Maternal Cousin 8:
Maternal Cousin 9:
Maternal Cousin 10:
Maternal Cousin 11:
Maternal Cousin 12:

Medical History: Respiratory (cont.)

Relative Lung Cancer
(age of onset)
Pneumonia
(age of onset)
Other Respiratory Disorder
(age of onset & disorder)
Self Pre-Teens
Mother
Father
Brother 1:
Brother 2:
Sister 1:
Sister 2:
Maternal Grandmother 60's
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Maternal Aunt 4:
Maternal Uncle 1:
Maternal Uncle 2:
Maternal Cousin 1:
Maternal Cousin 2:
Maternal Cousin 3:
Maternal Cousin 4:
Maternal Cousin 5:
Maternal Cousin 6:
Maternal Cousin 7:
Maternal Cousin 8:
Maternal Cousin 9:
Maternal Cousin 10:
Maternal Cousin 11:
Maternal Cousin 12:

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

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

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

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

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

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

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

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 Teens
Mother
Father
Brother 1:
Brother 2:
Sister 1:
Sister 2:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1: Teens 20's
Maternal Aunt 2:
Maternal Aunt 3:
Maternal Aunt 4:
Maternal Uncle 1:
Maternal Uncle 2:
Maternal Cousin 1:
Maternal Cousin 2:
Maternal Cousin 3:
Maternal Cousin 4:
Maternal Cousin 5:
Maternal Cousin 6:
Maternal Cousin 7:
Maternal Cousin 8:
Maternal Cousin 9:
Maternal Cousin 10:
Maternal Cousin 11:
Maternal Cousin 12:

Medical History: Genital/Reproductive (cont.)

Relative Cancer of the Uterus
(age of onset)
Varicocele Other Genital/Reproductive Disorder
(age of onset & disorder)
Self Teens , Cysts were due to birth control
Mother
Father
Brother 1:
Brother 2:
Sister 1:
Sister 2:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Maternal Aunt 4:
Maternal Uncle 1:
Maternal Uncle 2:
Maternal Cousin 1:
Maternal Cousin 2:
Maternal Cousin 3:
Maternal Cousin 4:
Maternal Cousin 5:
Maternal Cousin 6:
Maternal Cousin 7:
Maternal Cousin 8:
Maternal Cousin 9:
Maternal Cousin 10:
Maternal Cousin 11:
Maternal Cousin 12:

Medical History: Skin

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

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

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:
Brother 2:
Sister 1:
Sister 2:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Maternal Aunt 4:
Maternal Uncle 1: 80's
Maternal Uncle 2:
Maternal Cousin 1:
Maternal Cousin 2:
Maternal Cousin 3:
Maternal Cousin 4:
Maternal Cousin 5:
Maternal Cousin 6:
Maternal Cousin 7:
Maternal Cousin 8:
Maternal Cousin 9:
Maternal Cousin 10:
Maternal Cousin 11:
Maternal Cousin 12:

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

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

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

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

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

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

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

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

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

Relative Other Sight/Hearing/Olfactory Disorder
(age of onset & disorder)
Self
Mother
Father
Brother 1:
Brother 2:
Sister 1:
Sister 2:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Maternal Aunt 4:
Maternal Uncle 1:
Maternal Uncle 2:
Maternal Cousin 1:
Maternal Cousin 2:
Maternal Cousin 3:
Maternal Cousin 4:
Maternal Cousin 5:
Maternal Cousin 6:
Maternal Cousin 7:
Maternal Cousin 8:
Maternal Cousin 9:
Maternal Cousin 10:
Maternal Cousin 11:
Maternal Cousin 12:

Medical History: Other

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

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