Autosaved at

Confidential Donor Contact 2016

This part of your profile WILL NOT be released to the recipients or posted online.
Full Name
Date of Birth
Age
Home Phone Number
Work Phone Number
Cell Phone Number
E-Mail address
Current mailing address

Previous Egg Donation Experience

This part of your profile WILL NOT be released to the recipients or posted online.
Have you been an egg donor before? Yes No
If yes, what was the date?
Name of agency used?
Clinic/Doctor
Number of eggs retrieved?
Pregnancy? Yes No
What is your desired compensation?
$
Is it negotiable? Yes No
Please note: No contact will be made without your verbal consent.
Name of Physician (primary or OB/Gyn)
Address:
Phone Number:
How did you hear about Open Arms Consultants, Inc?
Please note that every effort is made to keep the identity of the donors and recipients confidential. Despite our best efforts, no absolute guarantees can be made in this regard.

Physical Characteristics:

Identifying information WILL NOT be released to the recipients or posted online.
Month/Year of Birth:
Race:
*Height:
Weight:
Hair (check what apply)
Balding
Thin
Average
Curly
Wavy
Straight
Complexion:
Fair
Medium
Dark
Olive
Freckles
Acne:
None
Mild
Moderate
Severe
Hair color:
Eye Color:
Bone type/bone structure:
Small
Medium
Large
Which are you?
Right handed
Left handed
Ambidextrous
Blood type if known:
Religion born into:
Current religion:
Married:
Yes
No
Number of pregnancies:
Number of children:
# girls:
# boys:
Their ages:
Born healthy?
Yes
No
If no, please explain:
Born with extremely high or low weight?
Yes
No
If yes, please explain:
Number of miscarriages:
# abortions:
# ectopics:
Did you need any medical assistance to conceive your children?
Yes
No
Do you have legal and physical custody of all your children?
Yes
No
If no, please explain:
Have you ever been arrested or convicted of a crime/felony?
Yes
No
If yes, please explain:
Have you ever been under the care of a psychiatrist
(hospitalization, medication, ongoing therapy)?
Yes
No
If yes, please explain:

EDUCATION:

Year Completed high school:
GPA
College Entrance Exam Scores:
SAT
ACT
Currently in college, pursuing degree in:
Completed college, degree in:
Year
GPA
Currently pursuing advance degree in:
Completed advanced degree in:
Year
GPA
List subjects most enjoyed:
Did you like school and why?
What would you like to do in the future?
Do you have any special talents (ie: musical, artistic, sporting ability, creative skills)?
What do you like doing in your spare time?
How would you describe yourself (outgoing, passive, moody, sensitive, introverted, etc?
How do you get along with other people? (Parents, friends, boss, etc..)
How do you solve your personal problems and make decisions
(quickly, after carefully exploring all points of view, with deliberation, etc..)?
What is important to you?
Why are you considering becoming an egg donor?
During the egg donation, whom can you expect to receive emotional support from?
Is your husband/partner aware of his responsibilities in the medical process
and is he willing to cooperate?
Is there anything you consider important that has not been covered in these forms?

Physical Characteristics of the Family

Please describe your family members by the following characteristics.
Mother
Father
Brother 1
Brother 2
Brother 3
Sister 1
Sister 2
Sister 3
Paternal Grandfather
Maternal Grandfather
Paternal Grandmother
Maternal Grandmother

Personal Health History

Do you currently have allergies?
Yes
No
If yes, are they related to:
Food
Drugs
Environmental
Other
Please list below substances and reactions produced:
Please describe any childhood allergies you have outgrown:
Do you have normal hearing?
Yes
No
Condition of teeth (check one)
Poor
Fair
Good
Do you wear eyeglasses/contacts?
Yes
No
If yes,
Farsighted
Nearsighted
Other (specify)
Do you wear eye glasses/contacts at all times?
Yes
No
Do you wear eyeglasses/contacts only to read?
Yes
No
Does any member of your family wear eyeglasses/contacts?
Yes
No
For what purpose?
To read only
Farsighted
Nearsighted
Other (specify)
Did you or any member of your family have to wear eyes glasses/contacts at an early age (from birth to preteen years)?*****
Yes
No
Relationship
Your diet (check one):
Vegetarian
non-vegetarian
Kosher
Your diet (check one):
Poor
Average
Excellent
How much exercise do you get?
None
Occasionally
Regularly
What type of exercise? Have you ever had surgery?
Yes
No
If yes, please explain:
Have you had any major radiation exposure or X-ray exposure?
Yes
No
If yes, please explain:
Have you ever been treated for any of the below:
Syphillis Yes No How many times? When was the last time?
Chlamydia Yes No How many times? When was the last time?
Pelvic Inflammatory Disease (PID) Yes No How many times? When was the last time?
Gonorrhea Yes No How many times? When was the last time?
Have any of your sexual partners ever had any of the below?
Non-specific urethritis (NSU) Yes No When?
Chlamydia Yes No When?
Venereal warts Yes No When?
Herpes Yes No When?
Other sexually transmitted diseases Yes No When?
Have you ever had any major infectious illnesses such as Hepatitis, pneumonia, etc?
Yes
No
If yes, please explain:
Have you ever served overseas in the military?
Yes
No
If yes, when and where? Have you ever been exposed to “agent orange” or any other herbicides or chemicals in Vietnam or elsewhere (forest service, highway maintenance, etc)?
Yes
No
If yes, please provide date and explain: Please list any medication you are currently taking including over the counter medications, herbs, birth control and vitamins: Have you ever used or currently use any of the following drugs?
Have you ever used or currently use any of the following drugs?
Marijuana
Cocaine
Barbiturates
Narcotics/Opiates
Heroin
Methadone
Morphine
Opium
Amphetamines
Tranquilizers
PCP
Inhalants
Other Drugs
Do you drink alcoholic beverages?
Yes
No
If so, which kind?
Beer
Wine
Liquor
Approximately how many? Per day Per week How much drinks? When (give years) If yes, how often?
Have you ever smoked cigarettes?
Yes
No
If yes, when started?
When stopped?
How many packs a day?
How long have you been smoking regularly?

Past Gynecologic History

What was the first day of your last menstrual period?
How old were you when you first noticed breast development?
How old were you when you first noticed pubic hair growth?
How old were you when you had your first period?
How old were you when you began to have regular periods?
How many days are there from the first day of one period to the first day of the next period?
How many total days of menstrual flow do you have?
How many “heavy flow” days do you have during your period?
Describe any discomfort you have associated with your period?
When does this discomfort start and how long does it last?
Describe any discomfort with intercourse:
List any forms of contraception you have used in the past:
Contraception 1
Date Started Date Stopped Type Reason for stopping
Contraception 2
Date Started Date Stopped Type Reason for stopping
Contraception 3
Date Started Date Stopped Type Reason for stopping
List any PAP smear abnormalities you have had in the past?
When was you last PAP smear?
* Result:
When was your last mammogram?
Result:
List any past infections/irritations of your pelvic organs:

Donor General Health

Please mark if you are now or have recently experienced any of the following
Problems with Vision Yes No
Double Vision Yes No
Blurred Vision Yes No
Loss of vision Yes No
Problems with hearing Yes No
Ringing in ears Yes No
Earache Yes No
Loss of balance Yes No
Problems with your sense of smell Yes No
Frequent sinus pain, congestion or drainage Yes No
Frequent or sever headaches Yes No
Difficulty in swallowing Yes No
Sores in your mouth or gums Yes No
Bleeding from your gums Yes No
Pain in any of your teeth Yes No
Lumps or Bumps in your neck Yes No
Chest Pain Yes No
Any pain with exertion Yes No
Shortness of breath Yes No
Difficulty in sleeping at night Yes No
A need to be propped up on pillows while sleeping Yes No
Waking up in the middle of night with shortness of breath Yes No
Fevers of chills Yes No
Waking up at night soaked in sweat Yes No
Hot flashes Yes No
Rapid heart beat Yes No
Breast pain Yes No
Persistent lump in your breast Yes No
Discharge of any kind from your breast Yes No
Heartburn or stomach pain Yes No
Pelvic pain or bloating Yes No
Back or joint pain Yes No
Swelling of your feet Yes No
Painful or enlarged veins in your legs Yes No
Nervousness Yes No
Irritability Yes No
Persistant unexplained fatigue Yes No
Constipation or diarrhea Yes No
Urinating more frequently than every 2 hours Yes No
Waking up in the middle of night to urinate Yes No
Ancestry
Do you have any Jewish ancestors?
Yes
No
Unknown
If yes, have you been tested as a carrier of the following?
Tay Sachs
Cystic fibrosis
Gaucher
If yes, result:
Do you have any African ancestors?
Yes
No
Unknown
If yes, have you been tested as a carrier of Sickle cell disease?
Yes
No
If yes, result:
Do you have any Mediterranean (Greek or Italian) ancestors?
Yes
No
Unknown
If yes, have you been tested as a carrier of Thalassemia?
Yes
No
If yes, result:
Do you have any Oriental ancestors?
Yes
No
Unknown
If yes, have you been tested as a carrier of Thalassemia?
Yes
No
If yes, result:
What level of schooling did your mother reach?
What is her current occupation?
What level of schooling did your father reach?
What is his current occupation?
Are you adopted?
Yes
No
If yes, do you know your biological parents medical history?
Yes
No

Family Medical History

Place an check in the applicable boxes to indicate problems YOU or one of your relatives has had.
Mental Health
Schizophrenia You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Manic Depressive You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Depression You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Attention Deficit Disorder You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Muscles/Bones/Joints
Muscular Dystrophy You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Other chronic muscles diseases You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Lupus You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Deformity of the spine You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Osteoporosis You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Dwarfism You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Heredity of low back disease You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Arthritis You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Congenital hip problems You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Gout You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Club feet You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Tourrette's Syndrome You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Other You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Sight/smell/sound
Deafness before age 60 You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Deformity of ear You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Cataracts before age 60 You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Blindness You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Glaucoma You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Deviated Septum You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Other Sight/Smell/Sound problems You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Skin
Acne You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Eczema You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Edema (swelling) You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Coffee colored skin spots You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Skin cancer You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Pigmentation disorder You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Other skin problems You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Other
Early death (< 50 years old) Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Chromosome problems You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Inguinal Hernia You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Place an “check” in the applicable boxes to indicate problems YOU or one of your relatives has had.
Heart You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Stroke You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Heart Attack You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Heart Disease You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Hardening of arteries You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Congenital Heart defects You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
High Blood Pressure You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Aneurism You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Blood You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Anemia You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Sickle Cell Anemia You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Hemophilia or other bleeding problems You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Leukemia You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Immune Deficiency You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Other blood disorder You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Blood Clots You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Respiratory (lungs) You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Hay Fever You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Asthma You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Emphysema You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Tuberculosis You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Lung cancer You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Pneumonia You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Gastrointestinal You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Ulcer of stomach/duodenum You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Gallstones You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Hepatitis A You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Hepatitis B You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Other Liver Disease You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Ulcerative Colitis You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Crohn's Disease You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Cystic Fibrosis You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Jaundice You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Intestinal cancer You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Other cancer/problem of digestive system You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Place an “X” in the applicable boxes to indicate problems YOU or one of your relatives has had.
Metabolic/Endocrine You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Diabetes mellitus (specify type 1 or 2) You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Low Blood Sugar You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Thyroid Cancer You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Adrenal dysfunction or disorder You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Goiter You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Other thyroid disease You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Hyperactivity You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Urinary You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Kidney disease You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Rectal Disorder You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Other You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Genital/Reproductive System You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Un-descended testicles You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Malformed penis You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Prostate Cancer You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Miscarriages (3 or more) You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Stillborns (2 or more) You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Uterine fibroids You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Ovarian cysts You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Cervical Cancer You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Neurological You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Migraines You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Mental retardation You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Senility before age 50 You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Multiple sclerosis You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Cerebral palsy You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Epilepsy/Seizures You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Hydrocephalus (water on the brain) You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Disorder of spinalcord You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Parkinson's Disease You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Myasthenia gravis You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Spinabifida (open spine) You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Paralysis/paraplegia You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Huntington's Disease You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Gaucher's Disease You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Wilson's Disease You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Other You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Place an “X” in the applicable boxes to indicate problems YOU or one of your relatives has had.
Cystic Fibrosis You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Down's Syndrome You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Lymph edema You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Alcoholism and/or Cirrhosis of the Liver You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Drug abuse, misuse, or addiction You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Breast Cancer You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Other Cancers You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Obesity You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Clef lip and/or palate You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Other You Your Mother Your Father Your Siblings Paternal & Maternal Grandparents Paternal & Maternal Aunts/Uncles Your First Cousins
Has any member of your family including yourself, had a problem or defect at birth of any of the following body systems (please include first cousins, and great-grandparents)?
Bone, muscles, joints, limbs Yes No Who/relation When Occurred Seriousness
Gastrointestinal system Yes No Who/relation When Occurred Seriousness
Nervous system, brain, spinal cord Yes No Who/relation When Occurred Seriousness
Blood circulation Yes No Who/relation When Occurred Seriousness
Respiratory System Yes No Who/relation When Occurred Seriousness
Organ (heart, lung, kidneys, etc) Yes No Who/relation When Occurred Seriousness
Genital/Urinary Yes No Who/relation When Occurred Seriousness
Metabolic (hormones, enzymes, etc) Yes No Who/relation When Occurred Seriousness
Do you have any brothers or sisters who died in infancy or childhood?
Yes
No
If yes, what was the cause?
Are there any known genetic diseases or conditions that run in your family?
Yes
No
If yes, what are they?
Has any one in your family including your self and your first cousins, experienced recurring and/or chronic physical symptoms that have been evaluated by a physician?
Yes
No
If yes, please explain:
The following space may be used if you need more room to explain any of the conditions listed in your family medical history: