Donor Number 976

General Information

Donor Code:
976
Ethnic Origin:
Canadian, English, French, German, Italian
Blood Type:
O Positive
Hair Color:
Brown
Type of Hair:
Wavy
Thickness of Hair:
Average
Age at Time of Retrieval:
22-23
Eye Color:
Brown
Complexion Relative to Race:
Medium
Bone Structure:
Small
Height:
5'5"
Weight:
120
Handedness:
Right-Handed

Yoga, rock climbing, camping, hiking and anything outdoors. She loves cooking, photography and animals.

Education Status: Undergraduate Student

Area of Study: Accounting, Finance

Vision: Good, does wear lenses

Hearing: Excellent

Dentition: Excellent, orthodontia required

Allergies: Seasonal Allergies, Gluten, Tomatos, Peaches, Oranges

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: Alive and in his 70's, Healthy

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

Maternal Grandfather: Died in his 70's, Lung cancer in his 70's, smoker

Maternal Grandmother: Died in her 30's, Hodgkin's disease in her 30's, smoker

Father: Alive and in his 50's, Healthy, melanoma (excess sun exposure)

Mother: Alive and in her 50'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: Pseudocholinesterase deficiency (carrier) HFE-Associated Hereditary Hemochromatosis (mild condition) 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: No

Face: Oval shaped, average sized, average forehead set, no freckles, no cleft in chin

Lips: Thin upper lip, medium lower lip

Nose: Straight, with straight profile

Ears: Medium sized, attached earlobes, slightly stick out.

Eyes: Almond shape, medium in size, average width apart, long lashes

Eyebrows: Thick and curved

Summary: She is extremely smart and was able to easily prepare her own medications without much guidance. She is honest and displays a great deal of integrity, always making sure we were up to date on her past information. She is physically fit and has gorgeous eyes and a warm, welcoming smile.

 

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

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

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

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

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

Medical History: Blood

Relative Anemia
(age of onset)
Sickle Cell
(age of onset)
Hemophilia
(age of onset)
Leukemia
(age of onset)
Self 20's
Mother
Father
Brother 1:
Sister 1:
Sister 2:
Sister 3:
Sister 4:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Uncle 1:
Maternal Uncle 2:
Paternal Aunt 1:
Paternal Aunt 2:
Paternal Uncle 1:
Paternal Uncle 2:
Paternal Cousin 1:
Paternal Cousin 2:
Paternal Cousin 3:
Paternal Cousin 4:
Paternal Cousin 5:
Paternal Cousin 6:
Paternal Cousin 7:

Medical History: Blood (cont.)

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

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

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

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

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

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

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

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: Pre-Teens Pre-Teens This is her paternal half brother
Sister 1:
Sister 2:
Sister 3:
Sister 4:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Uncle 1:
Maternal Uncle 2:
Paternal Aunt 1:
Paternal Aunt 2:
Paternal Uncle 1:
Paternal Uncle 2:
Paternal Cousin 1:
Paternal Cousin 2:
Paternal Cousin 3:
Paternal Cousin 4:
Paternal Cousin 5:
Paternal Cousin 6:
Paternal Cousin 7:

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

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

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

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

Medical History: Skin

Relative Acne
(age of onset)
Scarring Acne
(age of onset)
Eczema
(age of onset)
Psoriasis
(age of onset)
Self Teens Teens 20's
Mother
Father Teens
Brother 1:
Sister 1:
Sister 2: Teens 20's
Sister 3:
Sister 4: Teens
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Uncle 1:
Maternal Uncle 2: Teens Teens
Paternal Aunt 1:
Paternal Aunt 2:
Paternal Uncle 1:
Paternal Uncle 2:
Paternal Cousin 1:
Paternal Cousin 2:
Paternal Cousin 3:
Paternal Cousin 4:
Paternal Cousin 5: Teens
Paternal Cousin 6:
Paternal Cousin 7:

Medical History: Skin (cont.)

Relative Skin Cancer
(age of onset)
Pigmentation Disorders
(age of onset)
Other Skin Disorder
(age of onset & disorder)
Self Teens --acne scars are barely noticeable on her face
Mother
Father 20's
Brother 1:
Sister 1:
Sister 2:
Sister 3:
Sister 4:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Uncle 1:
Maternal Uncle 2:
Paternal Aunt 1:
Paternal Aunt 2:
Paternal Uncle 1:
Paternal Uncle 2:
Paternal Cousin 1:
Paternal Cousin 2:
Paternal Cousin 3:
Paternal Cousin 4:
Paternal Cousin 5:
Paternal Cousin 6:
Paternal Cousin 7:

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

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

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

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

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

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

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

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

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

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

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

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:
Sister 1:
Sister 2:
Sister 3:
Sister 4:
Maternal Grandmother 20's
Maternal Grandfather 20's
Paternal Grandmother
Paternal Grandfather
Maternal Uncle 1: 20's
Maternal Uncle 2: 30's 20's
Paternal Aunt 1:
Paternal Aunt 2:
Paternal Uncle 1:
Paternal Uncle 2:
Paternal Cousin 1:
Paternal Cousin 2:
Paternal Cousin 3:
Paternal Cousin 4:
Paternal Cousin 5:
Paternal Cousin 6:
Paternal Cousin 7:

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 20's
Mother 40's
Father
Brother 1:
Sister 1:
Sister 2: 20's
Sister 3:
Sister 4:
Maternal Grandmother 30's Hodgkin's disease
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Uncle 1:
Maternal Uncle 2:
Paternal Aunt 1:
Paternal Aunt 2:
Paternal Uncle 1:
Paternal Uncle 2:
Paternal Cousin 1:
Paternal Cousin 2:
Paternal Cousin 3:
Paternal Cousin 4:
Paternal Cousin 5:
Paternal Cousin 6:
Paternal Cousin 7: