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Introduction
Personal Bio
Education Information
Health / Reproductive History
Family / Genetic History


First Name:

Jaime

This donor is Available!
Donor #

77080

Please complete the following information about each blood relative:
Grandfather
Paternal
Grandmother
Paternal
Grandfather
Maternal
Grandmother
Maternal
Year of Birth 1934 1940 1939 1940
Alive/Deceased Deceased Alive Alive Alive
Hair Color Brown Brown Brown Brown
Eye Color Green Blue Hazel Blue
Height 5 feet 9 inches 5 feet 6 inches 6 feet 1 inches 5 feet 8 inches
Weight 165 135 200 180
Occupation Contractor House wife Retired House wife
Highest Education Level Achieved High School Graduate High School Graduate High School Graduate High School Graduate
If deceased, age at time of death. 78
List serious medical illnesses or hospitalizations. If deceased, list cause of death. Alzheimer's Diabetes (controlled with diet & exercise)
Father Mother
Alive/Deceased Alive Alive
Year of Birth 1965 1965
Hair Color Sandy Blond Brown
Eye Color Green Blue
Height 6 feet 2 inches 5 feet 10 inches
Weight 190 150
Occupation Sales Manager Flight Attendant
Highest Education Level Achieved High School Graduate Master's Degree
If deceased, age at time of death.
List serious medical illnesses or hospitalizations. If deceased, list cause of death.
Sibling 1 Sibling 2 Sibling 3
Gender Male Female
Alive/Deceased Alive Alive
Year of Birth 1987 1991
Hair Color Blond Brown
Eye Color Blue Green
Height 6 feet 0 inches 5 feet 8 inches
Weight 190 140
Occupation Business Manager Dental Hygenist
Highest Education Level Achieved Bachelor's Degree Bachelor's Degree
If deceased, age at time of death.
List serious medical illnesses or hospitalizations. If deceased, list cause of death.
Do you have any Eastern European (Ashkenazi) Jewish, French Canadian or Cajun ancestors?

Not Sure

Please indicate the number of family members who have ever been diagnosed with any of the conditions below. These questions apply to YOU (except the last question) and any member of your family, including your grandparents, parents, siblings, aunts, uncles and cousins. Please provide as much detail as possible for each answer.

Fibromyalgia?

No

Fragile X Syndrome?

No

Hydrocephaly?

No

Nervous Breakdown?

No

Spina Bifida?

No

Systemic Lupus Erythematosus?

No

Stroke?

No

Tay Sachs?

No

More than 2 miscarriages?

No

Neurofibromatosis?

No

Hyperactivity?

No

Attention Deficit Disorder?

No

ADD-ADHD?

No

Learning problems, attention deficit disorder, or autism?

No

Physical birth defects (such as heart defect, cleft lip, club feet, extra fingers or toes)?

No

Babies who were stillborn or died/children or young adults who died?

No

Down syndrome or any other chromosome disorder?

No

Heart disease, including high blood pressure, arrhythmia, heart attack, heart failure, high cholesterol, atherosclerosis, coronary artery disease?

No

Diabetes, thyroid, or any other hormone disorder?

Yes

Family Members Diagnosed:
Relationship To You     Age at Diagnosis     Additional Information    

Maternal Grandfather

   

67

   

Controlled with diet and exercise

   
Bleeding disorders (such as hemophilia or von Willebrand disease)?

No

Blood clotting disorders such as thrombosis (blood clots in the veins or strokes)?

No

Anemia or thalassemia?

No

Mental retardation or low IQ?

No

Iron overload, hereditary hemochromatosis or cirrhosis of the liver?

No

Breathing problems, such as emphysema?

No

Blindness in one or both eyes, glaucoma, cataracts, color blindness or any other vision or eye problem?

No

Hearing loss in one or both ears or any outer ear abnormality?

No

Bones that break easily, osteoporosis or scoliosis?

No

Dwarfism or unusually short stature?

No

Joint or muscle problems (such as weakness, muscular dystrophy or MS)?

No

Seizures or epilepsy?

No

Huntington disease, Alzheimer disease, Parkinson disease, cerebral palsy or other nerve problems?

Yes

Family Members Diagnosed:
Relationship To You     Age at Diagnosis     Additional Information    

Paternal Grandfather

   

75

   

Only experienced this for 3 years prior to his death.

   
Anyone with reflux or chronic heartburn, hiatal hernia, gallstones, ulcers, colitis, irritable bowel syndrome, other gastrointestinal problems?

No

Serious skin conditions such as multiple birthmarks, lumps or bumps or scaly skin?

No

Cystic fibrosis (a severe lung disease)?

No

Kidney disease such as polycystic kidneys, missing or abnormal kidneys, kidney failure or kidney stones?

No

Any type of cancer, including leukemia, lymphoma and other blood cancers?

No

Anyone who is seriously overweight?

No

Eating disorders such as anorexia or bulimia?

No

Alcoholism or heavy alcohol use?

No

Recreational or prescription drug abuse?

No

Depression, suicide, or suicide attempts?

No

Other mental illness such as bipolar (manic depressive) disorder, Tourette syndrome, obsessive-compulsive disorder or schizophrenia, or anyone having treatment by a therapist or psychiatrist?

No

Asthma or eczema?

Yes

Family Members Diagnosed:
Relationship To You     Age at Diagnosis     Additional Information    

Sibling

   

7

   

My brother was diagnosed with asthma at 7 years old, no longer experiences any problems.

   
Any other medical problems not previously mentioned?

No

Known to die prior to the age of 60?

No