Introduction
Personal
Lifestyle
Health/Reproductive History
 
Health History
     

Blood type :

B+
 
Do you have any past or current medical problems? Please explain.
No.
 
Are you currently taking any medications? Please explain.
Loestrin-oral contraceptive
 

Do you or anyone in your family wear glasses or contacts?

I wear corrective lenses.
 
Do you or anyone in your family have a history of drug or alcohol abuse? Please explain.
Maternal Grandfather-alchoholism
 

List deceased family members:

 
Name
Relationship
Age at time of Death
Cause of Death
Pat. Grandfather
Pat Grandmother
Maternal Grandfather
 
 
 
 

Family and Personal Medical History

 
Medical Condition
SELF FAMILY COMMENTS
Physical malformations, e.g. cleft palate, club foot, congenital heart defect, etc.
No
No
Paralysis or crippling disorder e.g. muscular dystrophy, multiple sclerosis, cerebral palsy, spina bifida, etc.
No
No
Seizure, convulsions, or epilepsy
No
No
Sight, hearing, or speech impairments
No
No
Learning Disability
No
No
Mental retardation, e.g. Down's Syndrome, etc.
No
No
Hormonal disorder e.g. diabetes, thyroid, etc
No
Yes
Paternal Grandmother-diabetes
Arthritis (rheumatoid, osteo)
No
No
Allergies (food, seasonal), asthma, hay fever, eczema
No
No
Blood diseases e.g. hemophilia, sickle cell anemia, hepatitis, etc
No
No
Ovarian problems e.g. cysts, malignancy
No
No
Uterine problems e.g. fibroids, endometriosis, cervical disease
No
No
Memory loss, dementia, Alzheimer's
No
No
Osteoporosis
No
No
Kidney disorder (stones, failure, infection)
No
No
Cardiovascular problems e.g. high blood pressure, stroke, heart attack, etc.
No
Yes
Mother-high blood pressure. Paternal grandfather-heart attack
Alcoholism
No
Yes
Maternal Grandfather
Cancer (type/location)
No
Yes
Maternal Grandmother-breast cancer
Significant illness (cystic fibrosis, lupus, etc)
No
Yes
Mother-external lupus
Spontaneous abortions, miscarriages, stillbirths, neonatal deaths.
No
No
 
 
 
 
Psychological History
     

Have you or anyone in your family been diagnosed with a psychological disorder? Please explain who and the details.

No.
 
Have you or anyone in your family been diagnosed with depression? Please explain.
No.
 
Have you or has anyone in your family been on medication for a psychological condition? Please explain.
No.
 

Do you or anyone in your family have a history of hyperactivity/ADHD/ADD?

No.
 
 
 
 

Fertility History

     

Number of Children:

Males
none
Ages
Females
none
Ages
       
Number of Pregnancies
none    
      
 
Has anyone in your family had multiple births (i.e. twins, triplets)? Please explain
No.
 

Previous Donor?

Yes
 

What method of birth control are you currently using?

Birth Control Pills
 
 
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