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First Name: Jennifer
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Donor # 101
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| Please complete the following information about each blood relative:
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Grandfather
Paternal |
Grandmother
Paternal |
Grandfather
Maternal |
Grandmother
Maternal |
| Age |
died |
died |
76 |
68 |
| Hair Color |
Brown |
Light Brown |
Dark Brown |
Brown |
| Eye Color |
Blue |
Hazel |
Green |
Brown |
| Height |
5'10" |
5'6" |
5'11" |
5'4" |
| Weight |
200 |
125 |
210 |
125 |
| Describe Quality of Health,
List Medical Illness or Hospitalizations |
Great Health |
Great Health |
Good Health smoker |
Great Health |
| Occupation |
Pharmacy |
Pharmacy |
Insurance |
Loved to sew |
| Education Level |
BS Pharm |
BS Math |
H.S. |
H.S. |
| If Deceased, Age at death and Cause |
42, boating accident |
75, old age |
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Father |
Mother |
Sibling List Gender |
Sibling List Gender |
Sibling List Gender |
| Age |
64 |
50 |
F 18 |
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| Hair Color |
Brown |
Brown |
Brown |
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| Eye Color |
Brown |
Green |
Brown |
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| Height |
5'11" |
5'8" |
5'7" |
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| Weight |
200 |
140 |
120 |
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| Describe Quality of Health,
List Medical Illness or Hospitalizations |
Great Health |
Great Health |
Great Health |
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| Occupation |
Business owner |
Legal Secretary |
Photography |
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| Education Level |
BS |
BA |
H.S. |
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| If Deceased, Age at death and Cause |
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| Donors Children |
Children |
Children |
Children |
Children |
Children |
| Age |
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| Education Level |
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| Gender |
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| Hair Color |
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| Eye Color |
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| Describe Quality of Health,
List Medical Illness or Hospitalizations |
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| Height |
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| Weight |
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| Please indicate if any of the following applies to you, your
children or any other member of your biological family. Include parents,
siblings, aunts, uncles and cousins. Please provide detail as possible about each
answer.
| Details |
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Relationship and Name |
Age at Diagnosis |
| Mental Retardation |
No |
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| Down's Syndrome |
No |
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| Autism |
No |
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| Genetic Inherited Cond. |
No |
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| Multiple Sclerosis |
No |
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| Muscular Dystrophy |
No |
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| Cystic Fibrosis |
No |
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| Fibromyalgia |
No |
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| Fragile X Syndrome |
No |
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| Huntington's Disease |
No |
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| Hydrocephaly |
No |
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| Diabetes |
No |
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| Manic Depression |
No |
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| Thyroid Condition |
No |
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| Dwarfism |
No |
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| Eating Disorders |
No |
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| Epilepsy |
No |
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| Seizure Disorder |
No |
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| Schizophrenia |
No |
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| Suicide/ Attempted |
No |
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| Suffers from Depression |
No |
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| Nervous Breakdown |
No |
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| Drug/Alcohol Addiction |
No |
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| Insanity |
No |
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| Heart Trouble |
No |
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| Congenital Heart Defect |
No |
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| Spina Bifida |
No |
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| Systemic Lupus Erythematosus |
No |
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| Cancer |
No |
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| Stroke |
No |
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| Kidney Disorder |
No |
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| Tay Sachs |
No |
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| Thalessemia |
No |
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| Hemophilia |
No |
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| Blindness |
No |
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| Deafness |
No |
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| Stillborn/Child Death |
No |
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| More than 2 miscarriages |
No |
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| Learning Disabilities |
No |
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| Cleft Lip or Palate |
No |
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| Nervous Breakdown |
No |
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| Neurofibromatosis |
No |
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| Club Foot |
No |
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| Hyperactivity |
No |
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Attention Deficit disorder
ADD-ADHD |
No |
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