Donor Number 551

General Information

Donor Code:
551
Ethnic Origin:
English, German
Blood Type:
B Positive
Hair Color:
Red
Type of Hair:
Wavy
Thickness of Hair:
Thick
Age at Time of Retrieval:
28-29
Eye Color:
Blue
Complexion Relative to Race:
Fair
Bone Structure:
Small
Height:
5'6"
Weight:
135
Handedness:
Right-Handed

Activities that use muscle memory: country swing dancing, martial arts and horse back riding. Also reading and music.

Education Status: Undergraduate Degree Obtained

Area of Study: Anthropology, History

Vision: Excellent, does not wear lenses

Hearing: Excellent

Dentition: Good, orthodontia required

Allergies: None known

Hospitalization: None known

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

Tobacco Usage: Does not smoke

Drug Usage: Tests NEGATIVE for Drugs of Abuse.

Paternal Grandfather: Alive and in his 80's, Healthy, hay fever in his 20s, smoker

Paternal Grandmother: Died in her 50's, Car accident in her 50s

Maternal Grandfather: Died in his 70's, Heart attack in his 70s, smoker

Maternal Grandmother: Alive and in her 80's, Healthy

Father: Alive and in his 50's, Healthy, elevated blood pressure in his 50s, hay fever in his 20s, smoker

Mother: Alive and in her 50'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:

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 6/30/2015.

UPDATED HEALTH HISTORY:

No new information reported at this time.

Donor Communication (Type): Open

Limited Available? No

Past Pregnancy: Yes

Face: Oval shape, average size, average forehead set, few freckles, one dimple on each side

Lips: Thin upper lip, medium lower lip

Nose: Straight with a straight profile, average width and length, small nostril flare

Ears: Small, attached lobes, average distance from face

Eyes: Small almond eyes with average setting and medium length lashes

Eyebrows: Medium, angled

Summary: This donor is very down to earth and makes you feel comfortable the second you begin speaking with her. She is non-judgmental and her presence puts you at ease. She is someone you could spend hours talking to about a variety of different subjects.

 

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

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

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
Sister 1:
Sister 2: Had a mild case of Thrush due to prenate. medication dr. had prescribe mom.
Sister 3:
Sister 4:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Maternal Uncle 1:
Paternal Uncle 1:
Maternal Cousin 1:
Maternal Cousin 2:
Maternal Cousin 3:
Maternal Cousin 4:
Maternal Cousin 5:
Paternal Cousin 1:
Paternal Cousin 2:
Paternal Cousin 3:

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

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

Medical History: Blood

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

Medical History: Blood (cont.)

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

Medical History: Respiratory

Relative Hay Fever
(age of onset)
Asthma
(age of onset)
Emphysema
(age of onset)
Tuberculosis
(age of onset)
Self
Mother
Father 20's
Sister 1:
Sister 2:
Sister 3: Teens
Sister 4:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather 20's
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Maternal Uncle 1:
Paternal Uncle 1: 20's
Maternal Cousin 1:
Maternal Cousin 2:
Maternal Cousin 3:
Maternal Cousin 4:
Maternal Cousin 5:
Paternal Cousin 1:
Paternal Cousin 2:
Paternal Cousin 3:

Medical History: Respiratory (cont.)

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

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

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

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

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

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

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

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

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

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

Medical History: Skin

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

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

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

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

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

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

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

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

Medical History: Muscles/Bones/Joints (cont.)

Relative Myasthenia Gravis
(age of onset)
Other Muscle/Bone/Joint Disorder
(age of onset & disorder)
Self
Mother
Father
Sister 1:
Sister 2:
Sister 3:
Sister 4:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Aunt 2:
Maternal Aunt 3:
Maternal Uncle 1:
Paternal Uncle 1:
Maternal Cousin 1:
Maternal Cousin 2:
Maternal Cousin 3:
Maternal Cousin 4:
Maternal Cousin 5:
Paternal Cousin 1:
Paternal Cousin 2:
Paternal Cousin 3:

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

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

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

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

Medical History: Other

Relative Alcoholism
(age of onset)
Drug Abuse or Addiction
(age of onset)
Smoker/Tobacco Use
(age of onset)
Self
Mother
Father 20's
Sister 1:
Sister 2:
Sister 3:
Sister 4:
Maternal Grandmother
Maternal Grandfather 20's
Paternal Grandmother
Paternal Grandfather 20's
Maternal Aunt 1:
Maternal Aunt 2: 20's
Maternal Aunt 3:
Maternal Uncle 1:
Paternal Uncle 1: 20's
Maternal Cousin 1:
Maternal Cousin 2:
Maternal Cousin 3:
Maternal Cousin 4:
Maternal Cousin 5:
Paternal Cousin 1:
Paternal Cousin 2:
Paternal Cousin 3:

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