EGG DONOR PROFILE Please do not use the "&" character anywhere in your application. Use the word "and". Thank you. Step 1 of 10 10% Thank you for applying to be a donor with the Donor Egg Bank USA network, now a California Cryobank company. We are appreciative of your willingness to participate in our program to help women and men who are unable to conceive. It is very important that we learn as much as possible about your personal and extended family medical history. This information is necessary to help us accept you to our frozen donor program as well as give our client’s insight into your background for the donor selection process. Please provide complete and accurate information to the following questions. Any information you provide during the donation process will be used to determine your eligibility for participation in the program. Information may also be shared with the Intended Parents and their healthcare providers after your identifying information is removed. Please fill in all blanks completely. Please complete all questions. Incomplete profiles will not be accepted or returned. Do not provide identifying information such as jobs, schools, towns, names of relatives, or other identifying information. Please write legibly and provide as much detail as possible. GENERAL INFORMATION Full Name First Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Primary PhoneOK to leave message? Yes No E-mail Address Best way to contact you? Email Call Text Date of Birth Month Day Year Are you able to provide detailed information about your relatives on both your maternal and paternal sides of the family? Including parents, siblings, grandparents, aunts, and uncles.Detailed Information Yes No How did you hear about us? Requested compensation?Have you donated your eggs before? Yes No If yes, please explain: What is your height (in feet & inches)? What is your current weight (in lbs.)? Have you ever spent time in jail? Yes No If yes, please explain: Have you ever been convicted of a crime? Yes No If yes, please explain: Are you adopted? No Yes – I know my biological family history. Yes – I do not know my biological family history. PHYSICAL APPEARANCEWhat race and/or ethnicity best represents you?CaucasianEast IndianBlack/African AmericanMiddle Eastern/ArabicHispanic/LatinoNative Hawaiian/Pacific IslanderAsianAmerican Indian/Alaska NativeMixed/Multi-racialWhat is your body frame/size? Small (Slim/Slender/Petite) Medium (Muscular/Athletic/Toned) Large (Heavy/Overweight) What is your dress size (in U.S. sizing)?What is your shoe size? Relative to your racial origin, how would you describe your complexion?Very FairFairMediumOliveDarkVery DarkWhat is your natural eye color?BlackBrownGreyBlueGreenHazelWhat style best describes your hair’s natural state? Curly Wavy Straight What texture best describes your hair’s natural state? Average Thin Thick What is your natural hair color?BlackBrown/Dark BrownLight BrownRed Brown/AuburnRedBlondeDark BlondeStrawberry BlondeWhat was your natural hair color as a child?BlackBrown/Dark BrownLight BrownRed Brown/AuburnRedBlondeDark BlondeStrawberry BlondeWhich is your dominant hand? Right Left Ambidextrous SKILLS, EDUCATION & WORK EXPERIENCEWhat is the highest level of education you have completed?GEDHigh SchoolTechnical Degree/CertificationSome CollegeSome GraduateCollege DegreeMajor or Concentration: Degree(s) Attained: What are your educational goals? Have you served in the military? No Yes Are you currently a student? No Yes – Full-time Yes – Part-time Please list the two (2) previous jobs you have held.(Do not include specific names or locations of employers/companies)Job Title/Duties:Year Began:Year End:Job Title/Duties:Year Began:Year End:Are you athletic? I do not participate in athletics Yes, I played sports recreationally Yes, I played sports in high school Yes, I played sports in college and/or professionally Which athletic activities have you participated in? (Check all that apply) Baseball / Softball Golf Soccer Running Gymnastics Tennis Skiing Martial Arts Surfing Dance Basketball Hockey Swimming Weight Training Triathlons Pilates Volleyball or Netball Horseback Riding Aerobic Classes (Tae Bo, Kickboxing, etc.) Cheerleading Please list any athletic achievements:Have you completed or are you currently involved in any volunteer work? No Yes Please describe below: Do you play any musical instruments? No Yes What instrument do you play? What languages do you speak, read, write, or understand? Please individually rate your aptitudes on each of the following abilities (1 = Poor, 5 = Excellent): Mathematical Ability: 1 2 3 4 5 Scientific Ability: 1 2 3 4 5 Athletic Ability: 1 2 3 4 5 Singing Ability: 1 2 3 4 5 Artistic Ability: 1 2 3 4 5 What subject did you most enjoy in school? What subject did you least enjoy in school? What is your favorite: Movie? Book? Food? Color? Animal? Season? MOTIVATIONS & PERSONALITYPlease explain your motivation for becoming an egg donor:Please describe your personality, character, and temperament. Please give examples:What are your hobbies, interests, and talents?If you were planning a dinner and could invite any four people (living or dead, famous or not), who would they be and why?Planning DinnerWhat are your future plans and goals?What message would you like to share with the intended parent(s)/offspring? GENERAL HEALTH HISTORYHow is your vision without corrective lenses? Poor Fair Good Excellent Do you wear corrective lenses or have you had corrective surgery? No Yes If yes for either corrective lenses and/or corrective eye surgery, for what problem(s)? Nearsighted Farsighted Both – Nearsighted and Farsighted Other If yes for either corrective lenses and/or corrective eye surgery, for what problem(s)? (OTHER) Age at diagnosis: How would you describe the condition of your teeth? Poor Fair Good Excellent Have you ever had dental braces or retainers? No Yes Do you use nicotine products (i.e. cigarettes, e-cigarettes, nicotine gum, etc.)? No Yes (If yes, how many do you use per week?) How many do you use per week? Do you consume alcoholic beverages? No Yes (If yes, how many do you drink per week?) How many do you drink per week? Which of the following best describes your type of diet? Regular/Non-Vegetarian Vegetarian Vegan How would you rate your diet (nutrition)? Poor Average Good Do you have any allergies? (Please check all that apply) No Yes – Food(s) Yes – Medication(s) Yes – Environmental For each allergy, please describe the specific substance and your reaction(s):Substance:Allergic Reaction to Substance:Age First Noticed:Substance:Allergic Reaction to Substance:Age First Noticed:Substance:Allergic Reaction to Substance:Age First Noticed:Substance:Allergic Reaction to Substance:Age First Noticed:Substance:Allergic Reaction to Substance:Age First Noticed:Please explain any allergies you have outgrown: How often do you exercise? Never Occasionally Regularly Have you ever had anesthesia? No Yes If yes, did you have any complications from anesthesia? No Yes (If yes, please explain) If yes, did you have any complications from anesthesia? GYNECOLOGY & FERTILITY HISTORYAt what age did your menstrual periods begin?How many total pregnancies have you had? Of these pregnancies, how many have resulted in the following (please include the year): Miscarriage: Abortion: Stillbirth: Live Birth: Please provide the following information regarding each of your live-born children:Male / FemaleDelivery Year:Complications:Weight:Height:Male / Female:Delivery Year:Complications:Weight:Height:Male / Female:Delivery Year:Complications:Weight:Height:Male / Female:Delivery Year:Complications:Weight:Height:Male / Female:Delivery Year:Complications:Weight:Height:Child Info ListChild 1 - Eye ColorChild 2 - Eye ColorChild 3 - Eye ColorChild 4 - Eye ColorChild 5 - Eye ColorChild Info List (Cont.)Child 1 - Hair ColorChild 2 - Hair ColorChild 3 - Hair ColorChild 4 - Hair ColorChild 5 - Hair Color FAMILY HISTORYWhat is your marital status? Single Married Divorced Separated Widowed With what religion do you affiliate? Mother’s Religion: Father’s Religion: Please provide the following characteristics about your biological family members. (Only enter "natural" eye/hair color.) Complexion: Please use fair, medium, olive, brown, ebony, etc. Body Frame: Please use small, medium, or large. Please note if family member wears glasses, contacts, or had corrective eye surgery (LASIK) on vision.Please provide the following characteristics about your biological family members.Mother - Eye ColorMother - VisionMother - Hair ColorMother - ComplexionMother - Body FrameMother - HeightPlease provide the following characteristics about your biological family members. (Cont.)Father - Eye ColorFather - VisionFather - Hair ColorFather - ComplexionFather - Body FrameFather - HeightPlease provide the following characteristics about your biological family members. (Cont. +1)Maternal Grandmother - Eye ColorMaternal Grandmother - VisionMaternal Grandmother - Hair ColorMaternal Grandmother - ComplexionMaternal Grandmother - Body FrameMaternal Grandmother - HeightPlease provide the following characteristics about your biological family members. (Cont. +2)Maternal Grandfather - Eye ColorMaternal Grandfather - VisionMaternal Grandfather - Hair ColorMaternal Grandfather - ComplexionMaternal Grandfather - Body FrameMaternal Grandfather - HeightPlease provide the following characteristics about your biological family members. (Cont. +3)Paternal Grandmother - Eye ColorPaternal Grandmother - VisionPaternal Grandmother - Hair ColorPaternal Grandmother - ComplexionPaternal Grandmother - Body FramePaternal Grandmother - HeightPlease provide the following characteristics about your biological family members. (Cont. +4)Paternal Grandfather - Eye ColorPaternal Grandfather - VisionPaternal Grandfather - Hair ColorPaternal Grandfather - ComplexionPaternal Grandfather - Body FramePaternal Grandfather - HeightPlease provide the following characteristics about your biological family members. (Cont. +5)Sibling 1 - Eye ColorSibling 1 - VisionSibling 1 - Hair ColorSibling 1 - ComplexionSibling 1 - Body FrameSibling 1 - HeightPlease provide the following characteristics about your biological family members. (Cont. +6)Sibling 2 - Eye ColorSibling 2 - VisionSibling 2 - Hair ColorSibling 2 - ComplexionSibling 2 - Body frameSibling 2 - HeightPlease provide the following characteristics about your biological family members. (Cont. +7)Sibling 3 - Eye ColorSibling 3 - VisionSibling 3 - Hair ColorSibling 3 - ComplexionSibling 3 - Body FrameSibling 3 - HeightPlease provide the following characteristics about your biological family members. (Cont. +8)Sibling 4 - Eye ColorSibling 4 - VisionSibling 4 - Hair ColorSibling 4 - ComplexionSibling 4 - Body FrameSibling 4 - HeightPlease provide the following characteristics about your biological family members. (Cont. +9)Sibling 5 - Eye ColorSibling 5 - VisionSibling 5 - Hair ColorSibling 5 - ComplexionSibling 5 - Body FrameSibling 5 - Height PLEASE ATTACH A MINIMUM OF EIGHT COLOR PHOTOGRAPHS (PNG OR JPEG FILES) OF YOURSELF; THREE AS A CHILD (AGE 10 AND UNDER) AND FIVE PHOTOS OF YOU AS AN ADULT. PLEASE ENSURE ALL PHOTOGRAPHS ARE CLEAR AND COMPLIMENTARY TO YOU. PLEASE ENSURE THE PHOTOS ARE DISCREET AND MODEST. (*APPLICATIONS WITHOUT PHOTOS WILL NOT BE ACCEPTED*)Upload Photographs Drop files here or Select files Max. file size: 1 MB, Max. files: 20. The undersigned agrees that, to the best of her knowledge and belief, the information provided in this application is complete and correct. The undersigned acknowledges that her profile, childhood and adult photographs may be placed on California Cryobank’s/Donor Egg Bank USA’s website for a possible recipient to view. The undersigned furthermore agrees to report to California Cryobank and the Fertility Center in which she cycles, any significant changes in the status of her health, especially in regards to sexually transmitted disease. NAME OF EGG DONOR (PRINTED): First EGG DONOR (SIGNATURE): Date MM slash DD slash YYYY INITIAL FAMILY MEDICAL HISTORY SCREENING Your family’s medical history is important to the health of any children conceived through your donations. As part of the donor screening process, you will speak with a genetic counselor to document a detailed personal and family medical history. Please provide initial family history information on the pages below. What are your ancestor’s ethnic backgrounds or countries of origin? (French, German, Cuban, Chinese, etc.). Mother’s Ancestries: Father’s Ancestries: Do you have any Jewish ancestry? No Yes – Maternal Yes – Paternal Yes – Both Maternal and Paternal Are you or any of your family members of Cree ancestry, an Indigenous Manitoba population, or from any of the following regions in Canada: Newfoundland, Bas-St-Laurent (Rimouski), Gaspésie, New Brunswick territories, Saguenay-Lac SaintJean/Charlevoix?Cree Ancestry No Yes Please provide the following information about your biological relatives.Include full relatives, half-siblings, half-aunts, and half-uncles and those relatives that are deceased.Son/DaughterSistersBrothersMaternal AuntsMaternal UnclesPaternal AuntsPaternal UnclesMotherCurrent Age, if LivingIf Deceased, Age and Cause of DeathFatherCurrent Age, if LivingIf Deceased, Age and Cause of DeathMaternal GrandmotherCurrent Age, if LivingIf Deceased, Age and Cause of DeathMaternal GrandfatherCurrent Age, if LivingIf Deceased, Age and Cause of DeathPaternal GrandmotherCurrent Age, if LivingIf Deceased, Age and Cause of DeathPaternal GrandfatherCurrent Age, if LivingIf Deceased, Age and Cause of DeathAre you taking, or have you ever taken, any prescription medications for longer than 2 weeks? No Yes If yes, state medication and reason for use: Have you ever had surgery or been hospitalized? No Yes If yes, specify surgeries or hospitalizations: Have you or any of your family members ever had genetic testing? No Yes If yes, please describe: INITIAL FAMILY MEDICAL HISTORY SCREENING Place a checkmark for each family member who has any of the medical issues listed below OR place a checkmark for “No One”, if appropriate. Please think about your family members’ surgeries, hospitalizations, and medications to help remember any health issues for which they have been treated. Include “half”-relatives and relatives who are deceased. Do not include individuals who are not biologically related to you. Alcoholism/Drug abuse Me Son/Daughter Mother Father Sister Brother Niece/Nephew Maternal-Grandparent Maternal-Aunt Maternal-Uncle Maternal-Cousin Paternal-Grandparent Paternal-Aunt Paternal-Uncle Paternal-Cousin No One Alzheimer disease/dementia prior to age 60 Me Son/Daughter Mother Father Sister Brother Niece/Nephew Maternal-Grandparent Maternal-Aunt Maternal-Uncle Maternal-Cousin Paternal-Grandparent Paternal-Aunt Paternal-Uncle Paternal-Cousin No One Anxiety/panic attacks Me Son/Daughter Mother Father Sister Brother Niece/Nephew Maternal-Grandparent Maternal-Aunt Maternal-Uncle Maternal-Cousin Paternal-Grandparent Paternal-Aunt Paternal-Uncle Paternal-Cousin No One Attention deficit/hyperactivity disorder Me Son/Daughter Mother Father Sister Brother Niece/Nephew Maternal-Grandparent Maternal-Aunt Maternal-Uncle Maternal-Cousin Paternal-Grandparent Paternal-Aunt Paternal-Uncle Paternal-Cousin No One Autism or Asperger syndrome Me Son/Daughter Mother Father Sister Brother Niece/Nephew Maternal-Grandparent Maternal-Aunt Maternal-Uncle Maternal-Cousin Paternal-Grandparent Paternal-Aunt Paternal-Uncle Paternal-Cousin No One Bipolar disorder Me Son/Daughter Mother Father Sister Brother Niece/Nephew Maternal-Grandparent Maternal-Aunt Maternal-Uncle Maternal-Cousin Paternal-Grandparent Paternal-Aunt Paternal-Uncle Paternal-Cousin No One Bleeding disorder/hemophilia Me Son/Daughter Mother Father Sister Brother Niece/Nephew Maternal-Grandparent Maternal-Aunt Maternal-Uncle Maternal-Cousin Paternal-Grandparent Paternal-Aunt Paternal-Uncle Paternal-Cousin No One Blindness prior to age 50 Me Son/Daughter Mother Father Sister Brother Niece/Nephew Maternal-Grandparent Maternal-Aunt Maternal-Uncle Maternal-Cousin Paternal-Grandparent Paternal-Aunt Paternal-Uncle Paternal-Cousin No One Brain tumor/abnormality Me Son/Daughter Mother Father Sister Brother Niece/Nephew Maternal-Grandparent Maternal-Aunt Maternal-Uncle Maternal-Cousin Paternal-Grandparent Paternal-Aunt Paternal-Uncle Paternal-Cousin No One Breast cancer Me Son/Daughter Mother Father Sister Brother Niece/Nephew Maternal-Grandparent Maternal-Aunt Maternal-Uncle Maternal-Cousin Paternal-Grandparent Paternal-Aunt Paternal-Uncle Paternal-Cousin No One Cerebral palsy Me Son/Daughter Mother Father Sister Brother Niece/Nephew Maternal-Grandparent Maternal-Aunt Maternal-Uncle Maternal-Cousin Paternal-Grandparent Paternal-Aunt Paternal-Uncle Paternal-Cousin No One Cleft lip or palate Me Son/Daughter Mother Father Sister Brother Niece/Nephew Maternal-Grandparent Maternal-Aunt Maternal-Uncle Maternal-Cousin Paternal-Grandparent Paternal-Aunt Paternal-Uncle Paternal-Cousin No One Colon cancer Me Son/Daughter Mother Father Sister Brother Niece/Nephew Maternal-Grandparent Maternal-Aunt Maternal-Uncle Maternal-Cousin Paternal-Grandparent Paternal-Aunt Paternal-Uncle Paternal-Cousin No One Club foot Me Son/Daughter Mother Father Sister Brother Niece/Nephew Maternal-Grandparent Maternal-Aunt Maternal-Uncle Maternal-Cousin Paternal-Grandparent Paternal-Aunt Paternal-Uncle Paternal-Cousin No One Depression Me Son/Daughter Mother Father Sister Brother Niece/Nephew Maternal-Grandparent Maternal-Aunt Maternal-Uncle Maternal-Cousin Paternal-Grandparent Paternal-Aunt Paternal-Uncle Paternal-Cousin No One Epilepsy or seizure disorder Me Son/Daughter Mother Father Sister Brother Niece/Nephew Maternal-Grandparent Maternal-Aunt Maternal-Uncle Maternal-Cousin Paternal-Grandparent Paternal-Aunt Paternal-Uncle Paternal-Cousin No One Extra or fused fingers or toes Me Son/Daughter Mother Father Sister Brother Niece/Nephew Maternal-Grandparent Maternal-Aunt Maternal-Uncle Maternal-Cousin Paternal-Grandparent Paternal-Aunt Paternal-Uncle Paternal-Cousin No One Genetic disorder Me Son/Daughter Mother Father Sister Brother Niece/Nephew Maternal-Grandparent Maternal-Aunt Maternal-Uncle Maternal-Cousin Paternal-Grandparent Paternal-Aunt Paternal-Uncle Paternal-Cousin No One Hearing problem/deafness prior to age 50 Me Son/Daughter Mother Father Sister Brother Niece/Nephew Maternal-Grandparent Maternal-Aunt Maternal-Uncle Maternal-Cousin Paternal-Grandparent Paternal-Aunt Paternal-Uncle Paternal-Cousin No One Heart attack prior to age 50 Me Son/Daughter Mother Father Sister Brother Niece/Nephew Maternal-Grandparent Maternal-Aunt Maternal-Uncle Maternal-Cousin Paternal-Grandparent Paternal-Aunt Paternal-Uncle Paternal-Cousin No One Heart defect Me Son/Daughter Mother Father Sister Brother Niece/Nephew Maternal-Grandparent Maternal-Aunt Maternal-Uncle Maternal-Cousin Paternal-Grandparent Paternal-Aunt Paternal-Uncle Paternal-Cousin No One Huntington’s disease Me Son/Daughter Mother Father Sister Brother Niece/Nephew Maternal-Grandparent Maternal-Aunt Maternal-Uncle Maternal-Cousin Paternal-Grandparent Paternal-Aunt Paternal-Uncle Paternal-Cousin No One Immune problem Me Son/Daughter Mother Father Sister Brother Niece/Nephew Maternal-Grandparent Maternal-Aunt Maternal-Uncle Maternal-Cousin Paternal-Grandparent Paternal-Aunt Paternal-Uncle Paternal-Cousin No One Kidney defect/disorder/cancer Me Son/Daughter Mother Father Sister Brother Niece/Nephew Maternal-Grandparent Maternal-Aunt Maternal-Uncle Maternal-Cousin Paternal-Grandparent Paternal-Aunt Paternal-Uncle Paternal-Cousin No One Learning disability/delay Me Son/Daughter Mother Father Sister Brother Niece/Nephew Maternal-Grandparent Maternal-Aunt Maternal-Uncle Maternal-Cousin Paternal-Grandparent Paternal-Aunt Paternal-Uncle Paternal-Cousin No One Melanoma Me Son/Daughter Mother Father Sister Brother Niece/Nephew Maternal-Grandparent Maternal-Aunt Maternal-Uncle Maternal-Cousin Paternal-Grandparent Paternal-Aunt Paternal-Uncle Paternal-Cousin No One Mental retardation Me Son/Daughter Mother Father Sister Brother Niece/Nephew Maternal-Grandparent Maternal-Aunt Maternal-Uncle Maternal-Cousin Paternal-Grandparent Paternal-Aunt Paternal-Uncle Paternal-Cousin No One Miscarriage/Stillbirth/Infertility Me Son/Daughter Mother Father Sister Brother Niece/Nephew Maternal-Grandparent Maternal-Aunt Maternal-Uncle Maternal-Cousin Paternal-Grandparent Paternal-Aunt Paternal-Uncle Paternal-Cousin No One Obsessive compulsive disorder Me Son/Daughter Mother Father Sister Brother Niece/Nephew Maternal-Grandparent Maternal-Aunt Maternal-Uncle Maternal-Cousin Paternal-Grandparent Paternal-Aunt Paternal-Uncle Paternal-Cousin No One Ovarian cancer Me Son/Daughter Mother Father Sister Brother Niece/Nephew Maternal-Grandparent Maternal-Aunt Maternal-Uncle Maternal-Cousin Paternal-Grandparent Paternal-Aunt Paternal-Uncle Paternal-Cousin No One Pancreatic cancer Me Son/Daughter Mother Father Sister Brother Niece/Nephew Maternal-Grandparent Maternal-Aunt Maternal-Uncle Maternal-Cousin Paternal-Grandparent Paternal-Aunt Paternal-Uncle Paternal-Cousin No One Parkinson disease prior to age 60 Me Son/Daughter Mother Father Sister Brother Niece/Nephew Maternal-Grandparent Maternal-Aunt Maternal-Uncle Maternal-Cousin Paternal-Grandparent Paternal-Aunt Paternal-Uncle Paternal-Cousin No One Pituitary disorder Me Son/Daughter Mother Father Sister Brother Niece/Nephew Maternal-Grandparent Maternal-Aunt Maternal-Uncle Maternal-Cousin Paternal-Grandparent Paternal-Aunt Paternal-Uncle Paternal-Cousin No One Prostate cancer prior to age 50 Me Son/Daughter Mother Father Sister Brother Niece/Nephew Maternal-Grandparent Maternal-Aunt Maternal-Uncle Maternal-Cousin Paternal-Grandparent Paternal-Aunt Paternal-Uncle Paternal-Cousin No One Schizophrenia Me Son/Daughter Mother Father Sister Brother Niece/Nephew Maternal-Grandparent Maternal-Aunt Maternal-Uncle Maternal-Cousin Paternal-Grandparent Paternal-Aunt Paternal-Uncle Paternal-Cousin No One Speech delay/lisp/stutter Me Son/Daughter Mother Father Sister Brother Niece/Nephew Maternal-Grandparent Maternal-Aunt Maternal-Uncle Maternal-Cousin Paternal-Grandparent Paternal-Aunt Paternal-Uncle Paternal-Cousin No One Spina bifida Me Son/Daughter Mother Father Sister Brother Niece/Nephew Maternal-Grandparent Maternal-Aunt Maternal-Uncle Maternal-Cousin Paternal-Grandparent Paternal-Aunt Paternal-Uncle Paternal-Cousin No One Stroke prior to age 50 Me Son/Daughter Mother Father Sister Brother Niece/Nephew Maternal-Grandparent Maternal-Aunt Maternal-Uncle Maternal-Cousin Paternal-Grandparent Paternal-Aunt Paternal-Uncle Paternal-Cousin No One Uterine cancer (other than cervical cancer) Me Son/Daughter Mother Father Sister Brother Niece/Nephew Maternal-Grandparent Maternal-Aunt Maternal-Uncle Maternal-Cousin Paternal-Grandparent Paternal-Aunt Paternal-Uncle Paternal-Cousin No One Tourette syndrome Me Son/Daughter Mother Father Sister Brother Niece/Nephew Maternal-Grandparent Maternal-Aunt Maternal-Uncle Maternal-Cousin Paternal-Grandparent Paternal-Aunt Paternal-Uncle Paternal-Cousin No One Vision problem Me Son/Daughter Mother Father Sister Brother Niece/Nephew Maternal-Grandparent Maternal-Aunt Maternal-Uncle Maternal-Cousin Paternal-Grandparent Paternal-Aunt Paternal-Uncle Paternal-Cousin No One Vitiligo/pigment disorder Me Son/Daughter Mother Father Sister Brother Niece/Nephew Maternal-Grandparent Maternal-Aunt Maternal-Uncle Maternal-Cousin Paternal-Grandparent Paternal-Aunt Paternal-Uncle Paternal-Cousin No One Death prior to 50 years of age, including childhood deaths Me Son/Daughter Mother Father Sister Brother Niece/Nephew Maternal-Grandparent Maternal-Aunt Maternal-Uncle Maternal-Cousin Paternal-Grandparent Paternal-Aunt Paternal-Uncle Paternal-Cousin No One Other cancer diagnosis prior to age 50 Me Son/Daughter Mother Father Sister Brother Niece/Nephew Maternal-Grandparent Maternal-Aunt Maternal-Uncle Maternal-Cousin Paternal-Grandparent Paternal-Aunt Paternal-Uncle Paternal-Cousin No One Other birth defects Me Son/Daughter Mother Father Sister Brother Niece/Nephew Maternal-Grandparent Maternal-Aunt Maternal-Uncle Maternal-Cousin Paternal-Grandparent Paternal-Aunt Paternal-Uncle Paternal-Cousin No One Other serious health problem Me Son/Daughter Mother Father Sister Brother Niece/Nephew Maternal-Grandparent Maternal-Aunt Maternal-Uncle Maternal-Cousin Paternal-Grandparent Paternal-Aunt Paternal-Uncle Paternal-Cousin No One Complete the following details for each family member’s health problem indicated on the prior grid pages.Provide as much detail as possible. Estimates for ages (e.g. Died in his 80s vs. Died at age 87) are acceptable when specifics are unknown.Family Member:Medical Condition/Symptoms and Treatment:Age at Diagnosis:Current Age or Age at Death:Contributing Factors/Additional Information:Family Member:Medical Condition/Symptoms and Treatment:Age at Diagnosis:Current Age or Age at Death:Contributing Factors/Additional Information:Family Member:Medical Condition/Symptoms and Treatment:Age at Diagnosis:Current Age or Age at Death:Contributing Factors/Additional Information:Family Member:Medical Condition/Symptoms and Treatment:Age at Diagnosis:Current Age or Age at Death:Contributing Factors/Additional Information:Family Member:Medical Condition/Symptoms and Treatment:Age at Diagnosis:Current Age or Age at Death:Contributing Factors/Additional Information:Family Member:Medical Condition/Symptoms and Treatment:Age at Diagnosis:Current Age or Age at Death:Contributing Factors/Additional Information:Family Member:Medical Condition/Symptoms and Treatment:Age at Diagnosis:Current Age or Age at Death:Contributing Factors/Additional Information:Family Member:Medical Condition/Symptoms and Treatment:Age at Diagnosis:Current Age or Age at Death:Contributing Factors/Additional Information:Family Member:Medical Condition/Symptoms and Treatment:Age at Diagnosis:Current Age or Age at Death:Contributing Factors/Additional Information:Family Member:Medical Condition/Symptoms and Treatment:Age at Diagnosis:Current Age or Age at Death:Contributing Factors/Additional Information:Family Member:Medical Condition/Symptoms and Treatment:Age at Diagnosis:Current Age or Age at Death:Contributing Factors/Additional Information:Family Member:Medical Condition/Symptoms and Treatment:Age at Diagnosis:Current Age or Age at Death:Contributing Factors/Additional Information:Family Member:Medical Condition/Symptoms and Treatment:Age at Diagnosis:Current Age or Age at Death:Contributing Factors/Additional Information:Family Member:Medical Condition/Symptoms and Treatment:Age at Diagnosis:Current Age or Age at Death:Contributing Factors/Additional Information:Family Member:Medical Condition/Symptoms and Treatment:Age at Diagnosis:Current Age or Age at Death:Contributing Factors/Additional Information:Medical Condition/Symptoms and Treatment 1:Contributing Factors/Additional Information 1:Medical Condition/Symptoms and Treatment 2:Contributing Factors/Additional Information 2:Medical Condition/Symptoms and Treatment 3:Contributing Factors/Additional Information 3:Medical Condition/Symptoms and Treatment 4:Contributing Factors/Additional Information 4:Medical Condition/Symptoms and Treatment 5:Contributing Factors/Additional Information 5:Medical Condition/Symptoms and Treatment 6:Contributing Factors/Additional Information 6:Medical Condition/Symptoms and Treatment 7:Contributing Factors/Additional Information 7:Medical Condition/Symptoms and Treatment 8:Contributing Factors/Additional Information 8:Medical Condition/Symptoms and Treatment 9:Contributing Factors/Additional Information 9:Medical Condition/Symptoms and Treatment 10:Contributing Factors/Additional Information 10:Medical Condition/Symptoms and Treatment 11:Contributing Factors/Additional Information 11:Medical Condition/Symptoms and Treatment 12:Contributing Factors/Additional Information 12:Medical Condition/Symptoms and Treatment 13:Contributing Factors/Additional Information 13:Medical Condition/Symptoms and Treatment 14:Contributing Factors/Additional Information 14:Medical Condition/Symptoms and Treatment 15:Contributing Factors/Additional Information 15: PhoneThis field is for validation purposes and should be left unchanged.
