Step 1 of 38 2% To become an egg donor, we need to learn some information about your personal and medical history. Your responses to these questions will help us to make sure that your health and medical history are compatible with the donation process and in particular for egg donors that it will not involve any increased risks for you. This effort will also help us to match you to an appropriate recipient. Please provide complete and accurate information to these questions. If you do not know the answer, ask a parent or family member. Any information you provide during the donation process, will remain completely confidential. Some of the information from this questionnaire will be given to the recipient(s) as noted but all identifying information is removed. A “yes” response will not necessarily eliminate you as a potential donor. Most people will have at least one of these conditions in themselves or a family member. The accuracy of the information you will be giving will provide information to potential families you may help to create. Instructions: Please fill in all blanks completely. Please complete all questions and write “N/A” if not applicable. Please be specific. Avoid expressions such as “natural” or “old age” (for causes of death). List any health problems as specifically as possible. If you do not know the age, put the approximate age or ask a relative to help you. List exact relationships such as “first cousin through my mother’s sister”. Please provide information on all the relatives requested. Do not write their names. If you have any questions, please call your donor coordinator. Name as it appears on your license(Required) First Middle Last Referred by Date of birth(Required) MM slash DD slash YYYY Place of birth(Required) Are you a US citizen or permanent resident?(Required) Yes No Driver's license number(Required) State(Required) 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 Marital status(Required)SingleMarriedDivorcedWidowedEngagedPartneredCompensation you are requesting(Required) Home address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone Number(Required)OK to leave message?(Required) Yes No Email address(Required) Type of Employment(Required) Donation HistoryHave you applied or been screened to be an egg donor before?(Required) Yes No Donor program informationProgram NameProgram Location Add RemoveHave you donated before?(Required) Yes No How many times did you donate or cycle?(Required)Are you currently enrolled as an egg donor in another program?(Required) Yes No Did you consult with your family when completing your family medical history?(Required) Yes No I hereby attest that all information disclosed in this application is accurate, true, and up-to-date to the best of my knowledge.(Required) Signature Personal Health HistoryAre you currently under a physicians care for any reason?(Required) Yes No Please explain(Required) Have you ever had any major illnesses such as amoebic dysentery (infection of the intestine), hypertension, blood clots, pneumonia, mononucleosis, etc.?(Required) Yes No When?(Required) Have you had any serious illness in the past?(Required) Yes No Please describe what happened?(Required) Did you have any complications or concerns with anesthesia?(Required) Have you had any hospitalization(s) not mentioned above?(Required) Please list any surgical procedures:Procedure nameProcedure date Add RemoveHave you ever had any broken bones?(Required) Yes No Which bones have you broken? Add RemoveHow many days in the preceding 12 months did you miss work because of illness (colds, flu, accidents, surgery, etc.)? Please explain:(Required)Has anyone in your family, including yourself, experienced recurring and/or chronic physical symptoms that have not been evaluated by a physician (Please include those symptoms that you may not consider serious.)?(Required) Yes No Please describe(Required) Have you ever been seen by psychiatrist, psychologist, social worker, counselor, or any other mental health professional for any reason?(Required) Yes No When, for how long and for what reason?(Required) Have you ever used medications such as anti-anxiety or antidepressants to treat an emotional or psychological problem?(Required) Yes No Anti-Anxiety and Antidepressants(Required)Medication NameReason UsedDate Last Used Add Remove Have you been vaccinated in the last 6 months?(Required) Yes No What were you vaccinated for?(Required) List all prescription medications that you have taken in the preceding 12 monthsMedicationHow OftenReason Add RemoveIf N/A, leave blankList all current over-the-counter medications (include hormones, vitamins, aspirin, antacids, laxatives, herbal & sports supplements, performance-enhancing supplements including steroids, etc.)MedicationHow OftenReason Add RemoveIf N/A, leave blankHave you ever taken anti-malarial drugs or had malaria?(Required) Yes No Have you had a blood transfusion?(Required) Yes No When?(Required) Have you ever been refused or denied as a blood donor?(Required) Yes No Why?(Required) Are you eligible to work in the United States?(Required) Yes No Is your work schedule flexible?(Required) Yes No Have you had radiation exposure or x-ray exposure?(Required) Yes No Please explain(Required) Have you ever been exposed to “agent orange” or any other herbicides or chemicals (military, forestry, highway service, or elsewhere)?(Required) Yes No Which substance(s)?(Required)When?Where? Add RemoveIn the preceding six months, were you exposed to the following in your job, living environment or while involved in hobbies? If yes to any of these, give dates and how often you have been exposed. Please consider carefully.Toxic Chemicals or Substances(Required) Yes No How Often?(Required) When?(Required) Sprays(Required) Yes No How Often?(Required) When?(Required) Fumes/Exhaust(Required) Yes No How often?(Required) When?(Required) Radiation(Required) Yes No How often?(Required) When?(Required) Flea Powder/Sprays(Required) Yes No How often?(Required) When?(Required) Lead/Lead products(Required) Yes No How often?(Required) When?(Required) Asbestos/Asbestos products(Required) Yes No How often?(Required) When?(Required) Pesticides/Herbicides(Required) Yes No How often?(Required) When?(Required) Cleaning solutions/solvents(Required) Yes No How often?(Required) When?(Required) Caffeine usageCups of coffee(Required)Daily number Cans of soda(Required)Daily number Cups of tea(Required)Daily number Energy drinks(Required)Daily number Do you currently smoke cigarettes?(Required) Daily Occasionally Rarely Never I used to smoke, but quit How many per day?(Required) What month/year did you quit?(Required) For how long did you smoke?(Required) What best describes your alcohol consumption?(Required) Never drink Rarely drink/Drink in small amount Even amounts through the week Drink in concentrated periods What type of alcohol do you usually consume?(Required) Beer Wine Liquor How many drinks do you usually consume in a week?(Required) 1-3 4-9 10-15 16 or more Have you ever used recreational or illicit drugs (cocaine, marijuana, LSD, heroin, barbiturates, narcotics, opiates, amphetamines, hallucinogens, tranquilizers, PCP, steroids, or etc.)?(Required) Yes No Which one(s) and when did you last use them?(Required)Drug NameLast Used Add RemoveDo you sleep well?(Required) Yes No How do you manage this?(Required) Have you had acupuncture, ear and/or body piercing or tattooing in which sterile procedures may not have been used?(Required) Yes No Do you have any tattoos or body piercings?(Required) Yes No Please list and describe all of your tattoos and body piercings:(Required)Date ReceivedSterile needles used? Add RemoveHave you ever had any problems with the law (i.e. DUI, custody issues, lawsuits)?(Required) Yes No Please explain(Required) Have you ever been incarcerated?(Required) Yes No Please explain(Required) Sexual orientation(Required) Heterosexual Homosexual Bisexual Number of current sexual partners:(Required) Number of sexual partners during the last six months:(Required) Total number of past sexual partners:(Required) In the last 6 months have you had unprotected sex (intercourse without a condom) with a new partner?(Required) Yes No Have you ever injected drugs or had a sexual partner who did so?(Required) Yes No Contraceptive HistoryCurrent contraception used:(Required) IUD Diaphragm Condom Birth control pills Rhythm Spermicide Depo-Provera Tubal Ligation None IUD type(Required) Birth control pill name(Required) How long have you taken birth control?(Required) Why did you start taking Birth Control Pills?(Required) When was your last Depo-Provera injection?(Required) To your knowledge, have you or any of your sexual partners been in contact with anyone or have you been personally tested or been treated for any of the following:HIV (AIDS)(Required) I have My partner has No When?(Required) How many times?(Required) When was the last time?(Required) NSU (non specific urethritis)(Required) I have My partner has No When?(Required) How many times?(Required) When was the last time?(Required) Syphilis(Required) I have My partner has No When?(Required) How many times?(Required) When was the last time?(Required) Gonorrhea(Required) I have My partner has No When?(Required) How many times?(Required) When was the last time?(Required) Chlamydia(Required) I have My partner has No When?(Required) How many times?(Required) When was the last time?(Required) Trichomonas(Required) I have My partner has No When?(Required) How many times?(Required) When was the last time?(Required) Venereal Warts(Required) I have My partner has No When?(Required) How many times?(Required) When was the last time?(Required) Herpes, Genital(Required) I have My partner has No When?(Required) How many times?(Required) When was the last time?(Required) Viral Hepatitis B or C(Required) I have My partner has No When?(Required) How many times?(Required) When was the last time?(Required) Genital Sores(Required) I have My partner has No When?(Required) How many times?(Required) When was the last time?(Required) Other sexually transmissible diseases(Required) I have My partner has No Disease type?(Required) When?(Required) How many times?(Required) When was the last time?(Required) Menstrual and reproductive history: for egg donorsAge at onset of menses(Required) Date of Last Menstrual Period(Required) Are your menstrual periods regular(Required) Yes No How long is your monthly cycle (first day of one period to first day of the next)?(Required) DaysAre you periods regular when you are not on any type of hormonal birth control such as the pill, etc.?(Required) Yes No How many times per year do you menstruate?(Required) How many days does your period usually last?(Required) DaysDo you bleed or spot between periods?(Required) Yes No Do you get menstrual cramps before, during, or after your period?(Required) Yes No Are your cramps:(Required) Mild Moderate Severe Do you use medication alleviate the pain?(Required) Yes No What medications do you use?(Required) Have you ever had any medical treatment for menstrual problems?(Required) Date of last pap smear(Required) Result(Required) Have you ever had an abnormal PAP(Required) Yes No When & why(Required) Have you ever been told you were infertile?(Required) Number of pregnancies(Required) Number of miscarriages(Required) Number of ectopic pregnancies(Required) Number of abortions(Required) Number of stillbirths(Required) Number of children(Required) Are you Currently Breastfeeding?(Required) Yes No Length of time it took you to get pregnantShortest If N/A, leave blankLongest If N/A, leave blankPregnancy HistoryBoy/GirlDelivery DateDelivery Type (Vaginal or C-Section)ComplicationsWeeks Pregnant when DeliveredHeight/Weight Add RemoveHave you ever had a pelvic infection requiring treatment with antibiotics(Required) Yes No When and why?(Required) Do you want children in the future?(Required) Yes No Please note that the remaining portion of this application will be shared and viewed by recipients. Please pay attention to the fact that the Intended Parents will be viewing your responses. Physical CharacteristicsAre you adopted?(Required) Yes No Blood Type(Required)A+A-B+B-AB+AB-O+O-I don't knowHeight(Required) Weight(Required) Age(Required)Please enter a number from 1 to 99.Recent weight loss/gain?(Required) Yes No Weight(Required) Change(Required) Gained Lost What was your weight at age 21?(Required) Do you have children of your own?(Required) Yes No How many?(Required) Sexual orientation(Required)HomosexualHeterosexualBisexualHave you been an egg donor before?(Required) Yes No How many times?(Required) Dominant hand(Required)Right HandedLeft HandedAmbidextrousBone structure(Required)SmallMediumLargeVery largeComplexion(Required)Very FairFairLightMediumOliveLight BrownDark BrownEbonyTan ability(Required)NoneSlightMediumEasy FreckleSkin condition(Required)OilyMediumDryCombinationDimples(Required) Yes No Eye color(Required)Blue BrownLt. BrownDark BrownGreenHazelEye set(Required)NarrowAverageWideEye size(Required)SmallAverageLargeEye shape(Required)RoundOvalAlmondNatural hair color(Required)BlackLight BlondeMedium BlondeDark BlondeLight BrownMedium BrownDark BrownRedHair type(Required)CurlyWavyStraightHair texture(Required)FineMediumCoarseHair fullness(Required)ThinMediumThickBaldness in family(Required) Yes No Premature graying(Required) Yes No At what age?(Required) Body and Facial Features(Required)SmallMediumLargeCondition of your teeth(Required)PoorFairGoodExcellentHave you had any periodontal or orthodontic work?(Required) Yes No At what age?(Required) Hearing(Required)PoorFairGoodExcellent(without corrective aids)Vision(Required)PoorFairGoodExcellent(without corrective lenses)Do you wear glasses or contacts or have you had laser surgery?(Required) Yes No Are/were you(Required) Nearsighted Farsighted Other Do you have astigmatism?(Required)(blurred vision due to an irregularity in the curvature of the cornea) Yes No Age diagnosed(Required) Do you have any allergies?(Required) Yes No Are they to:(Required) Food(s) Medication(s) Environmental Latex For each medication allergy, describe specific substance and reaction(s) and age first noticed(Required)SubstanceReactionAge Add RemovePlease list any childhood allergies that you have outgrown(Required) Add Remove Social History and HabitsReligion Born Into(Required) Religion practiced(Required) Education(Required)Did not Complete High SchoolReceived GEDCompleted high schoolCurrently in collegeCompleted collegeCurrently pursuing an advanced degreeCompleted advanced degreeDegree(Required) Pursuing a degree in(Required) GPA(Required) Did you have any learning disabilities or weaknesses in school?(Required) Yes No Describe(Required) Academic Strengths(Required)How many languages do you speak?(Required)Which languages?(Required) Add RemoveMusical Talent or Instrument(Required)InstrumentYears experience Add RemoveArtistic talent(Required)Athletic skills / Favorite sports(Required)Other skills/hobbies/talents/interests do you have(Required) Current Occupation(Required) How long have you been at your current job?(Required) Have you been out of the country in the past 6 months(Required)(Mexico etc.) Yes No When?(Required) Where?(Required) Do you plan on traveling outside the United States within the next 6 months?(Required) Yes No When?(Required) Where?(Required) HabitsExercise habits(Required) None Occasional Regular Type of exercise(Required) Your diet is(Required) Vegetarian Non-vegetarian Your diet is(Required) Poor Average Excellent Do you have any dietary restrictions?(Required) Reproductive HistoryNumber of children(Required)01234 Child #1Age(Required) Sex(Required) Eye color(Required) Hair color(Required) Frame size(Required) Grade in school(Required) Personality(Required) Artistic ability(Required) Intelligence(Required) Distinguishing characteristics(Required) Wears eye glasses(Required) Discipline problems(Required) Medications(Required) Dyslexia(Required) Reading difficulties(Required) Speech difficulties(Required) Any special services at school(Required) Seen by Social worker/ psychiatrist(Required) Grade functional level(Required) Normal, Above/below average Child #2Age(Required) Sex(Required) Eye color(Required) Hair color(Required) Frame size(Required) Grade in school(Required) Personality(Required) Artistic ability(Required) Intelligence(Required) Distinguishing characteristics(Required) Wears eye glasses(Required) Discipline problems(Required) Medications(Required) Dyslexia(Required) Reading difficulties(Required) Speech difficulties(Required) Any special services at school(Required) Seen by Social worker/ psychiatrist(Required) Grade functional level(Required) Normal, Above/below average Child #3Age(Required) Sex(Required) Eye color(Required) Hair color(Required) Frame size(Required) Grade in school(Required) Personality(Required) Artistic ability(Required) Intelligence(Required) Distinguishing characteristics(Required) Wears eye glasses(Required) Discipline problems(Required) Medications(Required) Dyslexia(Required) Reading difficulties(Required) Speech difficulties(Required) Any special services at school(Required) Seen by Social worker/ psychiatrist(Required) Grade functional level(Required) Normal, Above/below average Child #4Age(Required) Sex(Required) Eye color(Required) Hair color(Required) Frame size(Required) Grade in school(Required) Personality(Required) Artistic ability(Required) Intelligence(Required) Distinguishing characteristics(Required) Wears eye glasses(Required) Discipline problems(Required) Medications(Required) Dyslexia(Required) Reading difficulties(Required) Speech difficulties(Required) Any special services at school(Required) Seen by Social worker/ psychiatrist(Required) Grade functional level(Required) Normal, Above/below average Family Health HistoryHow many blood siblings are in your immediate family(Required)(including yourself and half siblings) Number of Brothers(Required) Number of Sisters(Required) Number of Maternal Aunts(Required) Number of Maternal Uncles(Required) Number of Paternal Aunts(Required) Number of Paternal Uncles(Required) Do you have any brothers or sisters that died in infancy or childhood?(Required) Yes No What was the cause?(Required) Are there any members of your family with a history of learning disabilities or autism?(Required) Yes No Please explain(Required) Describe genetic family members according to the following characteristics. Use natural eye and hair color; fair/dark, etc. complexion. If they are deceased, please list cause of death. Please do not put “natural” as a cause of death. If unknown, write “unknown.”Sister(s)Eye colorHair colorComplexionHeightWeightBone StructureOccupationAgeCause of death (if applicable) Add RemoveBrother(s)Eye colorHair colorComplexionHeightWeightBone StructureOccupationAgeCause of death (if applicable) Add RemoveMotherEye colorHair colorComplexionHeightWeightBone StructureOccupationAgeCause of death (if applicable) Add RemoveFatherEye colorHair colorComplexionHeightWeightBone StructureOccupationAgeCause of death (if applicable) Add RemoveMaternal GrandmotherEye colorHair colorComplexionHeightWeightBone StructureOccupationAgeCause of death (if applicable) Add RemoveMaternal GrandfatherEye colorHair colorComplexionHeightWeightBone StructureOccupationAgeCause of death (if applicable) Add RemovePaternal GrandmotherEye colorHair colorComplexionHeightWeightBone StructureOccupationAgeCause of death (if applicable) Add RemovePaternal GrandfatherEye colorHair colorComplexionHeightWeightBone StructureOccupationAgeCause of death (if applicable) Add Remove Carefully review the following list of medical problems and identify which ones you or one of your genetic relatives have or had. Please consider each condition carefully for each family member. Explain any conditions you check below, indicating which side of the family (maternal or paternal), the age at the time of onset, and any other pertinent information. If you and none of your indicated family members have a history of the specific medical condition, please indicate none.CancerBreast(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Colon or Intestinal(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Lung(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Ovarian or Uterine(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Prostate or Testicular(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Skin(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Stomach(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Thyroid(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Blood (e.g. leukemia)(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Other HeartStroke(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Heart Attack(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Congenital Heart Disease(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Heart Disease or Defect(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Hardening of the Arteries(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)High Blood Pressure(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)High cholesterol level(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)BloodAnemia(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Sickle-Cell Anemia(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Factor V Leiden thrombphilia (Blood clots or strokes)(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Hemophilia or other Bleeding/Clotting Disorders such as Von Willebrand’s Disease(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Immune Deficiency(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Leukemia(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Lymphoma or Swollen Lymph Nodes(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)HIV(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Thalassemia(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Polyarteritis Nodosa(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Other Blood Disorder(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.) RespiratoryAsthma(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Hay Fever(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Emphysema(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Tuberculosis(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Pneumonia(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Alpha-1 antitrypsin Disorder(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Blood in Sputum(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Other Lung Disease(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.) Gastro-intestinalAppendicitis(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Ulcer of Stomach or Duodenum(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Gallstones(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Hepatitis A,B or C(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Cirrhosis of the Liver(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Other Liver Disease(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Ulcerative Colitis(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Crohns Disease(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Pyloric Stenosis(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Multiple Polyps of the Colon(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Rectal Disorder(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Inflammatory Bowel Disease(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Any other problem of the digestive system(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.) Metabolic/endocrineDiabetes requiring insulin therapy(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Diabetes not requiring insulin therapy(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Childhood Diabetes(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Thyroid disorder(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Goiter(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Hypoglycemia(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Adrenal Dysfunction or Disorder(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Phenyl Ketonuria (PKU) or inherited Metabolism Disorder(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Obesity(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Dwarfism(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.) UrinaryKidney Problems(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Polycystic Kidney Disease(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Other disease/ defect of urinary tract (urethra, bladder, ureter)(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Genital/reproductiveHermaphroditism/ Ambiguous Genitals(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Hypospadias or undescended testicle(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Uterine Fibroids(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Ovarian Cysts or Ruptured(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Lumps or Cysts in Breast or Discharge(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Polycystic Ovarian Syndrome (PCOS)(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Pelvic Inflammatory Disease (PID)(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Endometriosis(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.) Reproductive outcomes2 or more Miscarriages(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Stillborn(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Premature Menopause(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Death of a newborn infant(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Childhood death(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Birth defects(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Infertility(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Premature Birth(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Depression(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Schizophrenia(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Manic Depressive or Bipolar Disorder(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Other mental health disorder requiring hospitalization(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Suicide Attempts(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Other mental health problems that warranted counseling (please list)(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.) Muscle/bone/jointsMuscular Dystrophy(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Achondroplasia – form of dwarfism with abnormal bone growth(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Other Chronic Muscle Disease(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Osteogenesis imperfecta (brittle bone disease)(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Loss of Muscle Coordination(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Osteoporosis(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Marfan Syndrome(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Arthritis(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Rheumatoid or Juvenile Arthritis(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Spinal Muscular Atrophy(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Hereditary Low Back Disorder or Deformity of Spine(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Reiter’s Disease(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Myasthenia Gravis(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Gout(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Metabolic Bone Disease (be more specific)(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Lupus (systemic lupus erythematosis – SLE)(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.) Sight/sound/smellDeafness before age 60(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Deformity of the ear(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Cataracts before age 50(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Blindness(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Color Blindness(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Severe Myopia(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Glaucoma(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Retinoblastoma(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Retinitis Pigmentosa(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Deviated Septum(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Any other Sensory Disorder(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.) SkinAcne(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Albinism(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Eczema(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Excessive Facial Hair (Hirsutism)(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Pigmentation Disorders(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Psoriasis(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Neurofibromatosis(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Other disorders of the skin(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Infectious Skin Disease(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)More than 5 purple- or coffee- colored spots on skin (size of quarter or larger)(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.) Congenital abnormalities/birth defectsCleft Lip / Palate(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Congenital Hip Problems(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Club Feet(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Heart Defect(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Hearing Problems(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Spina Bifida -Neural Tube (open spine)(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Microcephaly(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Holoprosencehpaly – a single-lobed brain structure and severe skull and facial defects(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Other Chromosomal abnormalitiesDown Syndrome(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Other (i.e. Turner, Fragile X, Klinefelter’s etc.)(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)OtherAlcoholism(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Drug abuse, Misuse or Addiction(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Premature degeneration of any organ system(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.)Any other condition not mentioned above(Required) None Self Mother Father Sibling Grandmother Aunt/Uncle Cousin Explanation(Required) (which side of family, age of onset, etc.) Genetic HistoryEthnic origin (e.g., French, Irish) please do not just put “Caucasian”Mother Father Race: Check all that apply for your ancestorsAfrican American Mother Father Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Eastern European (Ashkenazi) Jewish Mother Father Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Mediterranean (Greek, Italian) Hispanic Mother Father Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Indian (from India) Mother Father Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Southeast Asian (Laotian, Vietnamese, Cambodian) Mother Father Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather French Mother Father Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Canadian Mother Father Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Cajun Mother Father Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Have you or anyone in your family ever been tested positive as a carrier or had any of any of the following diseases?Blooms Syndrome(Required) Yes No Select the applicable type(Required) Disease Carrier-Negative Unknown Canavan(Required) Yes No Select the applicable type(Required) Disease Carrier-Negative Unknown Cystic Fibrosis(Required) Yes No Select the applicable type(Required) Disease Carrier-Negative Unknown Fabry Disease(Required) Yes No Select the applicable type(Required) Disease Carrier-Negative Unknown Familial Dysautonomia(Required) Yes No Select the applicable type(Required) Disease Carrier-Negative Unknown Familial Mediterranean Fever(Required) Yes No Select the applicable type(Required) Disease Carrier-Negative Unknown Fanconi Anemia Grp. C(Required) Yes No Select the applicable type(Required) Disease Carrier-Negative Unknown Gaucher(Required) Yes No Select the applicable type(Required) Disease Carrier-Negative Unknown Niemann-Pick type A(Required) Yes No Select the applicable type(Required) Disease Carrier-Negative Unknown Mucolipidosis type IV(Required) Yes No Select the applicable type(Required) Disease Carrier-Negative Unknown Sickle Cell(Required)
