Donor Number 318

General Information

Donor Code:

318

Ethnic Origin:

African American, American Indian, English, Irish

Blood Type:

O Positive

Hair Color:

Dark Brown

Type of Hair:

Curly

Thickness of Hair:

Average

Age at Time of Retrieval:

22-25

Eye Color:

Hazel

Complexion Relative to Race:

Medium

Bone Structure:

Medium

Height:

5'10"

Weight:

173

Handedness:

Right-Handed

Interests

Singing, video games, yard work, writing, books, crafting, outdoor activities, and spending time with her son.

Education

Education Status: General Educational Development (GED) Obtained

Area of Study: Biology, Wildlife and Fisheries Biology

General Health

Vision: Excellent, does not wear lenses

Hearing: Good

Dentition: Excellent, no orthodontia required

Allergies: None known

Hospitalization: 1990s, 2010s

Alcohol Usage: Does not drink alcohol

Tobacco Usage: Does not smoke

Drug Usage: Tests NEGATIVE for Drugs of Abuse.

Family Health

Paternal Grandfather: Died in his 50's, Cirrhosis of the liver in his 50's

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

Maternal Grandfather: Died in his 50's, Malignant brain tumor in his 50's, passed away due to complications associated with radiation treatment

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

Father: Died in his 40's, Passed away due to injuries resulting from a fall

Mother: Alive and in her 40's, Healthy

Siblings: At least one, 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:

MTHFR Deficiency

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 11/11/2014

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: Round in shape with average forehead set and light acne on her forehead, cheeks and chin

Lips: Full upper and lower lips

Nose: Wide shape, average in length, with a rounded tip

Ears: Medium in size, tucked back,attached lobes

Eyes: Almond shape, small size, average set

Eyebrows: Medium fullness, straight

Summary: She has a "take charge" presence about her. It is obvious she is intelligent and driven.

Donor Writing Sample/Essay

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

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

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

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

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

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

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

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

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

Medical History: Gastro-Intestinal

Relative	Ulcers (age of onset)	Hepatitis A (age of onset)
Self
Mother
Father
Brother 1:
Brother 2:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Uncle 1:
Maternal Uncle 2:
Maternal Uncle 3:
Paternal Aunt 1:
Paternal Uncle 1:
Maternal Cousin 1:
Maternal Cousin 2:		30's
Maternal Cousin 3:	40's
Maternal Cousin 4:
Maternal Cousin 5:
Maternal Cousin 6:
Paternal Cousin 1:
Paternal Cousin 2:
Paternal Cousin 3:
Paternal Cousin 4:
Paternal Cousin 5:
Paternal Cousin 6:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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