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Donor Number 1079

Inventory

Donor Number: 1079

This donor is not currently donating ?
This donor is no longer providing donations as part of our Anonymous Donor Program. This means that the donor has vials available for sale, but does not have any remaining vials in quarantine for future release. The only way additional vials may become available for this donor is in the event vials are released back to NW Cryobank by customers with previously purchased and stored vials wishing to release them back to the Cryobank. These specimens have never left our facility and carry our full motility guarantee.
ICI ?
If you plan to perform an intra-cervical insemination (also known as vaginal insemination) which is the placement of the sperm near, but not inside of the cervix, the ICI preparation is suitable. The insemination may be performed in the privacy of your own home without the assistance of a medical provider, in all states allowing this procedure.

ICI specimens are 'unwashed' and similar to a 'raw' ejaculate which contains natural nutrients, proteins, sperm cells, etc. Unwashed samples are similar to the deposit made during intercourse. https://www.nwcryobank.com/general-sperm-information/

ICI specimens may only be used for an intra-cervical insemination, unless the sample is put through a washing procedure by your medical provider. If the ICI specimen is placed directly into the cervix or the uterus, severe cramping and even shock may occur.

Once washed, it may be used for an IUI (intra-uterine insemination) or IVF (In-vitro Fertilization treatment). If you plan to have your medical provider perform your insemination, ask if they prefer you purchase an ICI (unwashed), or an IUI (washed) specimen. Most fertility doctors and/or clinics can wash specimens prior to treatments.

Note: If the specimen undergoes additional processing by your clinic prior to insemination, the motility guarantee will be void.
Out of Stock
IUI ?
If you plan to perform an intra-cervical insemination (also known as vaginal insemination) which is the placement of the sperm near, but not inside of the cervix, the IUI preparation is suitable. The insemination may be performed in the privacy of your own home without the assistance of a medical provider, in all states allowing this procedure.

Or, if you plan to have your medical provider perform the insemination, the IUI preparation may be required. It is best to ask if your provider prefers you purchase an ICI (unwashed), or an IUI (washed) specimen. Most fertility doctors and/or clinics can wash specimens prior to treatments. Note: If the specimen undergoes additional processing by your clinic prior to insemination, the motility guarantee will be void.

IUI specimens are "washed". The term "washed" means that the "raw" ejaculate is put through a density gradient to remove dead and poorly performing sperm, and other unnecessary contents. This process creates specimens with a high concentration of motile sperm. https://www.nwcryobank.com/general-sperm-information/)
12-50 remaining
ICI-IVF ?
ICI-IVF specimens are "unwashed" and similar to a "raw" ejaculate which contains natural nutrients, proteins, sperm cells, etc. Unwashed samples are similar to the deposit made during intercourse. These specimens have a lower sperm count than our standard vial making them suitable for an IVF procedure with a Fertility Clinic or Reproductive Endocrinologist.

These specimens are also suitable for an intra-cervical insemination (also known as vaginal insemination) which is the placement of the sperm near, but not inside of the cervix. The insemination may be performed in the privacy of your own home without the assistance of a medical provider, in all states allowing this procedure. Because the sperm count is lower than our standard vials, it might be advisable to consider purchasing 2 vials for each attempted insemination.

ICI specimens may only be used for an intra-cervical insemination, unless the sample is put through a washing procedure by your medical provider. If the ICI specimen is placed directly into the cervix or the uterus, severe cramping and even shock may occur.

Once washed, it may be used for an IUI (intra-uterine insemination) or IVF (In-vitro Fertilization treatment). If you plan to have your medical provider perform your insemination, ask if they prefer you purchase an ICI (unwashed), or an IUI (washed) specimen. Most fertility doctors and/or clinics can wash specimens prior to treatments.

Note: If the specimen undergoes additional processing by your clinic prior to insemination, the motility guarantee will be void.
Out of Stock
IUI-IVF ?
IUI-IVF specimens are "washed". The term "washed" means that the "raw" ejaculate is put through a density gradient to remove dead and poorly performing sperm, and other unnecessary contents. These specimens have a lower sperm count than our standard vial making them suitable for an IVF procedure with a Fertility Clinic or Reproductive Endocrinologist. Note: If the specimen undergoes additional processing by your clinic prior to insemination, the motility guarantee will be void.

These specimens are also suitable for an intra-cervical insemination (also known as vaginal insemination) which is the placement of the sperm near, but not inside of the cervix. The insemination may be performed in the privacy of your own home without the assistance of a medical provider, in all states allowing this procedure. Because the sperm count is lower than our standard vials, it might be advisable to consider purchasing 2 vials for each attempted insemination.
Out of Stock

Inventory lists are based on daily inventory counts. The listing does not include orders in progress. Orders will be filled on a first come, first serve basis and inventories may shift as orders process.

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General Information

Donor Code:
1079
Ethnic Origin:
British, Canadian, English, German
Blood Type:
AB Positive
Hair Color:
Brown
Type of Hair:
Straight
Thickness of Hair:
Average
Eye Color:
Brown
Complexion Relative to Race:
Medium
Bone Structure:
Small
Height:
5'11"
Weight:
145
Handedness:
Right-Handed

Loves music, plays several instruments at the youth symphonic level. Avid motorcycle enthusiast. Enjoys foreign language and traveling.

Education Status: Associates Student

Area of Study: Natural Resources

CMV Status (All donors test CMV-IgM Negative): Negative

Vision: Excellent, does not wear lenses

Hearing: Good

Dentition: Excellent, no orthodontia required

Allergies: None known

Hospitalization: None known

Alcohol Usage: Does not drink alcohol

Tobacco Usage: Does not smoke

Drug Usage: Tests NEGATIVE for Drugs of Abuse.

Paternal Grandfather: Died in his 60's, Alcoholism in his 40s

Paternal Grandmother: Alive and in her 80's

Maternal Grandfather: Alive and in his 70's

Maternal Grandmother: Died in her 60's

Father: Alive and in his 50's

Mother: Alive and in her 40's

Siblings: At least one sibling, all in good health

Genetic Screening Performed: Yes

This donor has been screened for more than 100 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 9/24/2015.

UPDATED HEALTH HISTORY:

No new information reported at this time.

Donor Communication (Type): Open

Limited Available? No

Past Pregnancy: Yes

Face: Square, average in size.

Lips: Small, thin upper lip, medium fullness lower lip.

Nose: Romanesque shape, long.

Ears: Small, tucked back, detached lobes.

Eyes: Medium in size, roundish-almond shaped, medium lashes.

Eyebrows: Medium fullness, angled.

Summary: This young man is extremely text book. He is strictly Yes Sir and yes Ma'am, always polite. He has a great smile and a warm glow. If you ask him something he never replies with a one word answer. When it comes down to it he is the kind of guy that will always have your back and always has great advice.

 

Childhood Photos

Price: $25

Some of our donors have agreed to provide photos in their childhood years. You may find 1-6 photosof the donor depending on the photos provided. Once purchased, the photos are available for viewing from your account. Per the stipulation of the donor, the photos are viewable, but not reproducible.

If you are purchasing photos in anticipation of purchasing donor eggs, please call to check inventory prior to purchase. Although rare, it is possible to purchase a donor photo and then find that the donor no longer has eggs available. As donor inventory is very dynamic, we are unable to offer refunds on photos because of donor inventory shortages.

Purchase Childhood Photo

Childhood Photos

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Expanded Profile

Price: $25

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, please understand that this was simply a new question that was not asked at the time that particular donor completed his/her application form, and consequently, we are unable to provide a response for that question.

If you are purchasing an expanded profile for a donor listed as "available on-line", the profile will be viewable from your account once we have processed your credit card which is typically 1 business day from the day you place the order. For expanded profiles listed as "available by mail", you can expect to receive those within 3 business days of placing your order.

This donor's expanded profile is available Online.

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Expanded Profile

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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:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Uncle 1:
Paternal Aunt 1:
Paternal Uncle 1:
Maternal Cousin 1:
Maternal Cousin 2:
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:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Uncle 1:
Paternal Aunt 1:
Paternal Uncle 1:
Maternal Cousin 1:
Maternal Cousin 2:
Paternal Cousin 1:
Paternal Cousin 2:
Paternal Cousin 3: Underweight at birth but made full recovery and became very healthy.

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:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Uncle 1:
Paternal Aunt 1:
Paternal Uncle 1:
Maternal Cousin 1:
Maternal Cousin 2:
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
Sister 1:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Uncle 1: 50's
Paternal Aunt 1:
Paternal Uncle 1:
Maternal Cousin 1:
Maternal Cousin 2:
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:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Uncle 1:
Paternal Aunt 1:
Paternal Uncle 1:
Maternal Cousin 1:
Maternal Cousin 2:
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:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Uncle 1:
Paternal Aunt 1:
Paternal Uncle 1:
Maternal Cousin 1:
Maternal Cousin 2:
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:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Uncle 1:
Paternal Aunt 1:
Paternal Uncle 1:
Maternal Cousin 1:
Maternal Cousin 2:
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
Sister 1:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Uncle 1:
Paternal Aunt 1:
Paternal Uncle 1:
Maternal Cousin 1:
Maternal Cousin 2:
Paternal Cousin 1:
Paternal Cousin 2:
Paternal Cousin 3: Teens

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:
Maternal Grandmother
Maternal Grandfather 60's COPD
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Uncle 1:
Paternal Aunt 1:
Paternal Uncle 1:
Maternal Cousin 1:
Maternal Cousin 2:
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:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Uncle 1:
Paternal Aunt 1:
Paternal Uncle 1:
Maternal Cousin 1:
Maternal Cousin 2:
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:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Uncle 1:
Paternal Aunt 1:
Paternal Uncle 1:
Maternal Cousin 1:
Maternal Cousin 2:
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:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Uncle 1:
Paternal Aunt 1:
Paternal Uncle 1:
Maternal Cousin 1:
Maternal Cousin 2:
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:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Uncle 1: 40's - Type 2 Diabetes
Paternal Aunt 1:
Paternal Uncle 1:
Maternal Cousin 1:
Maternal Cousin 2:
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:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Uncle 1:
Paternal Aunt 1:
Paternal Uncle 1:
Maternal Cousin 1:
Maternal Cousin 2:
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:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Uncle 1:
Paternal Aunt 1:
Paternal Uncle 1:
Maternal Cousin 1:
Maternal Cousin 2:
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:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Uncle 1:
Paternal Aunt 1:
Paternal Uncle 1:
Maternal Cousin 1:
Maternal Cousin 2:
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:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Uncle 1:
Paternal Aunt 1:
Paternal Uncle 1:
Maternal Cousin 1:
Maternal Cousin 2:
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:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Uncle 1:
Paternal Aunt 1:
Paternal Uncle 1:
Maternal Cousin 1:
Maternal Cousin 2:
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
Mother
Father
Sister 1:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Uncle 1:
Paternal Aunt 1:
Paternal Uncle 1:
Maternal Cousin 1:
Maternal Cousin 2:
Paternal Cousin 1:
Paternal Cousin 2:
Paternal Cousin 3:

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:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Uncle 1:
Paternal Aunt 1:
Paternal Uncle 1:
Maternal Cousin 1:
Maternal Cousin 2:
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:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Uncle 1:
Paternal Aunt 1:
Paternal Uncle 1:
Maternal Cousin 1:
Maternal Cousin 2:
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:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Uncle 1:
Paternal Aunt 1:
Paternal Uncle 1:
Maternal Cousin 1:
Maternal Cousin 2:
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:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Uncle 1:
Paternal Aunt 1:
Paternal Uncle 1:
Maternal Cousin 1:
Maternal Cousin 2:
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:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Uncle 1:
Paternal Aunt 1:
Paternal Uncle 1:
Maternal Cousin 1:
Maternal Cousin 2:
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:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Uncle 1:
Paternal Aunt 1:
Paternal Uncle 1:
Maternal Cousin 1:
Maternal Cousin 2:
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:
Maternal Grandmother 60's 60's
Osteoarthritis
Maternal Grandfather
Paternal Grandmother 80's 60's
Osteoarthritis
Paternal Grandfather
Maternal Aunt 1:
Maternal Uncle 1:
Paternal Aunt 1:
Paternal Uncle 1:
Maternal Cousin 1:
Maternal Cousin 2:
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:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Uncle 1:
Paternal Aunt 1:
Paternal Uncle 1:
Maternal Cousin 1:
Maternal Cousin 2:
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:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Uncle 1:
Paternal Aunt 1:
Paternal Uncle 1:
Maternal Cousin 1:
Maternal Cousin 2:
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:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Uncle 1:
Paternal Aunt 1:
Paternal Uncle 1:
Maternal Cousin 1:
Maternal Cousin 2:
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:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Uncle 1:
Paternal Aunt 1:
Paternal Uncle 1:
Maternal Cousin 1:
Maternal Cousin 2:
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
Sister 1:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather 40's Teens
Maternal Aunt 1:
Maternal Uncle 1:
Paternal Aunt 1:
Paternal Uncle 1:
Maternal Cousin 1:
Maternal Cousin 2:
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:
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt 1:
Maternal Uncle 1:
Paternal Aunt 1:
Paternal Uncle 1:
Maternal Cousin 1:
Maternal Cousin 2:
Paternal Cousin 1:
Paternal Cousin 2:
Paternal Cousin 3: