WPC  ~_/:\fPVtSfGb|Jf ktr U9+bލq 2&T&/:#*YN%$ܨ' FBKx7A':r>* WD!W=>F4jW]j=zCTM ?y?.זuDO1h6GU23:# F<0\h!c/!G~1H3c@eiO\A %a}V_YԬV: 8f g>{c WeMtկd0Rľ&>( d8R-Ϝ`mXFwU>kboD}PeP(xqބN((}z*=iFiX<YpYTs=v1mHWa&7-,P%_^8 $O'h#ULNq % 0: ^ w 4 # 2 m4 1K 72 1u 72y 0c bd 'r f bb a  f a f/ a1 fE aG f[ a] fq as f a f a f a ' bb fRfTaVb`jbba,f@aBb^VfabbQC#fab`b`--bdfb` bbb^b`@Nb`b^bb`5bb/Ybbb^bdHbdbd)bbbdSbdjbdbd2b`#b`2/b` B!a>FRb^b bdsb\TP05,,,,0(  Z6Times New Roman RegularX($USUS.,z. p-:i+003|xU(CEKQW]cioAutoList1A.A.A.A.A.A.A.A. A.3#37=CIQYag1.a.i.(1)(a)(i)1)a) i)(;3$2#  0  .3  0  Donorappl(p.13)091901 Donor ID # ________________ E?;,ȤDonorappl(p.8)091901 Donor ID # ________________TABLE B TABLE DTABLE CTABLE E@9TABLE FGTABLE GqTABLE Hp<TABLE IГTABLE J I?,Donorappl(p.(02)091901 Donor ID # ______________@TABLE LDonorappl(p.#) 091901 Donor ID # ______________Donorappl(p.18) 091901 Donor ID # ______________TABLE MxTABLE NDonorappl(p.3)091901 Donor ID # ______________8   TABLE ADonorappl(p.9)091901 Donor ID # ________________ G8 dd8W?  ,  U шqTABLE PDonorappl(p.2) 091901 Donor ID # ______________Donorappl(p.(2)091901 Donor ID # ______________ ##Xd#Donorappl(p. )091901 Donor ID # _______________ MoZ5n 6 Vo0X;$FXZ 0 @ PROCREATIVECRYOBANK,LLC     &a%&  XcWX%&a  DONORSMEDICALHISTORYQUESTIONNAIRE ~  V      ^  XXcWDONORFERTILITYHISTORY    f      n      v  "    Haveyoueverhadasemenanalysisdonebefore:_______Yes______No   ЀIfyes,pleaselistthedatesanypertinentinformation: f      n    b   V _________Date__________SpermCount_______Motility__________Other_______  X   V _____________________________________________________________________ r   V _____________________________________________________________________  h  Whatwerethereasonsforobtainingthesemenanalysis?___________________________________________________________   _________________________________________________________________________________________________________  x Haveyoueverappliedorbeenscreenedtobeaspermdonor?______Yes0  ______No%% ЀIfyes,nameofspermbank:_____________________________________When:______________________________________ V Wereyouacceptedasaspermdonor?_______Yes_______No L ЀIfyes,howlongdidyoudonate:_____________Months  Howmanysuccessfullivebirthsresultedformyourdonations:___________ * Haveyoueverdonatedbloodorplasma?_______Yes_______No   Haveyoueverbeenrefusedasablooddonor?_______Yes______No : ЀIfyes,when?___________________Reason:__________________________________________________________________ l  Haveyouhadabloodtransfusioninthelast12months?______Yes_______No ! ЀIfyes,dateofbloodtransfusion:______/______/______ J" Haveyoueverbeentoldthatyouwereinfertile?______Yes_______No @$ ЀIfyes,when?____________________Reason?_______________________________________________ % Isthereanyhistoryoffertilityproblemsinyourfamily(difficultyconceiving,historyofrecurrentmiscarriage)?______Yes______No !' ЀIfyes,pleaseexplain______________________________________________________________________________________ !P( Didyourparentshavedifficultyconceiving?_______Yes______No j# * Doyouhaveanybrotherswhohavefertilityproblems?______Yes______No $`", Doyouhaveanyuncleswhohavefertilityproblems?_______Yes______No z&#. Didyourmothertake_diehylstilbestrol_Ԁ(DES)oranydrugswhileshewaspregnantwithyou? (p%0 _____Yes______NoIfyes,pleaseexplain_____________________________________________________ (4&1 DoyouwearJockeytypeunderwear?_______Yes________No N*'3  MaritalStatus:____________________________ +D)5 Areyouatwin?______Yes______No ,*6 Ifyes,Identical_______Yes______No ^-*7 Areyouatriplet?_______Yes_______No ".+8  ,,  /-:  E?;,   _DONORHEALTHHISTORY   Doyoucurrentlyhaveanyallergies?_______Yes______No ' ЀIfyes,aretheyrelatedto:______Food_____Drugs_____Environmental(Pollen)_____Other J Pleaselistspecificsubstanceandreaction(s)produced: s *\ddd Xdd Xdd X,&,&, dd ,dd +  $ZZ $  Substance '_  'ЀReaction _               l     l    e   e   Pleaselistanychildhoodallergiesyouhaveoutgrown:____________________________________________________ |  ________________________________________________________________________________________________ @  Doyouhaveyourvisioncheckedatregularintervals?________Yes_______No i  Howisyourvision?(Withoutglasses):_____Poor_____Fair____Good____Excellent - Doyouwearglassesorcontactlenses?______Yes______No P Areyou:_____Nearsighted_____FarsightedOther(specify):____________________________________  Yourvisionis:Righteye:20/_____Lefteye:20/_____ y Areyouorafamilymembercoloredblind?_______Yes_______No = ЀIfyes,familymember:___________________________________________________ ` Doyouhaveyourhearingcheckedatregularintervals?______Yes______No  Doyouhavenormalhearing?______Yes_______No M ЀIfno,pleaseexplain:______________________________________________________________________________ p Doyouhaveyourteethcheckedatregularintervals?______Yes______No  Conditionofyourteeth(checkone):_____Poor_____Fair_____Good______Excellent ]   NUTRITION D"  Yourdietis:______Vegetarian_______NonVegetarian i$ Yourdietis(checkone):_____Poor_____Fair_____Good_____Excellent -% Pleaseindicatehowoftenperweekyoueatordrinkthefollowingfoodsorbeverages: ' Eggs(withyolks)0 4 0 4&4&0 & &0< & &0<&<&   D 0&&_____________________________=!)&& Friedfoods0  04&&0 4&4&0 & &0< & &0<&<&0&&0D&&0D&D&______________________________"`*&& Redmeat(steak,hamburger,pork,lamb,etc.)0 < 0<&<&0&&0D&&0D&D&______________________________"$ +&& Coldcuts(sausage,salami,hotdogs,bacon,etc.)0 < 0<&<&0&&0D&&0D&D&______________________________# ,&& Creamoroilbasedsaladdressing,creamsauces,mayonnaise0  0&&0D&&0D&D&______________________________M$!-&& Soups,frozenentreesandprocessed(cannedorfrozen)0  0&&0D&&0D&D&______________________________%p".&& Freshvegetableandfruits0 4 0 4&4&0 & &0< & &0<&<&0&&0D&&0D&D&______________________________%4#/&& Wholegraincerealsandbreads0 0 & &0< & &0<&<&0&&0D&&0D&D&______________________________�&& Beveragescontainingsugar(includecoffeeorteawithaddedsugar)0  0D&&0D&D&______________________________]'$1&& Howoftendoyouaddsalttoyourfoods0 0< & &0<&<&0&&0D&&0D&D&_____________________________!(%2&& Wholemilk,dairyproducts(milk,yogurt,icecream,cheese,butter,etc.)0 D 0D&D&_____________________________(D&3&& Skimmilkandskimmilkproducts0 0 & &0< & &0<&<&0&&0D&&0D&D&_____________________________)'4&& Cookies,pastries,cakes,etc.0 0 & &0< & &0<&<&0&&0D&&0D&D&_____________________________m*'5&& Saltysnackfoodpotatochips,nuts,cornchips,pretzels,etc.0  0&&0D&&0D&D&_____________________________1+(6&& Beveragesand/orfoodproductscontaining_Aspertame_,NutraSweetetc.0 D 0D&D&_____________________________+T)7&& Ѐ ,*8   /&-< Hc HGE:; H  EXERCISE0  &&  Howmuchtimedoyouspendperweekparticipatinginthefollowingrecreational,occupationalorhouseholdactivities: $ VerystrenuousactivitiesBaseball,bicycling,crosscountryskiing,running,singlesracquetsports,lapswimming,diggingshoveling.   StrenuousactivitiesLeisurebicycling,doublesracquetsports,downhillskiing,jogging,leisureswimming,heavygardening,constructionwork. 4 ModerateactivitiesSoftball,briskwalking,dancing,golf,hiking,volleyball,cleaning,mopping.  VeryStrenuous:0  04&&_____________/wk.D  4&4& Strenuous:0  04&&_____________/wk. , 4&4& Moderate:0  04&&_____________/wk.T 4&4& Howoftendoyouexerciseaerobically(20minutesormoreofcontinuous),rhythmicexerciseatmoderatestrenuousintensity? <  ______________________________________________________________________________________________________   Doyouregularlyexercisetoincreaseyourstrength(forexample:Nautilus,weighttraining,pullups,pushups,situps)?______Yes ( _____No L Doyouregularlydostretchingexercises?______Yes_____No   MEDICAL 8  Doyouhaveanycurrentmedicalproblems/conditions?_____Yes_____No  ЀIfyes,pleasedescribe:____________________________________________________________________________  &a%%&aHaveyouoranyofyourpartnerseverhad: h *\,dd@ dd @dd \,&,&,8 dd , dd , dd , dd , dd +  ,, Syphilis &T, &Yes  0  No  0!   ӀMyself/Partner 0"  /1  ӀWhen "0#  "  $#   $   %   &   ' Gonorrhea  @(   @)   @*   @+   @, _NSU_Ԁ(nonspecificurethritis)  8-   8.   8/   80   81 Chlamydia  2   3   4   5   6 VenerealDisease  H7   H8   H9   H:   H; Herpes  @!<   @!=   @!>   @!?  @!@  *1\3,d,d8 dd 8 dd  dd  dd  dd \,&,&,8 dd , dd , dd , dd , dd +  4"@4" Othersexuallytransmissiblediseases  "A   "B   "C   "D   "E Undescendedtesticlesatbirth  #P!F   #P!G   #P!H   #P!I   #P!J Infectionoftheprostate  H%"K   H%"L   H%"M   H%"N   H%"O Infectionofthetesticlesorepididymis  &$P   &$Q   &$R   &$S   &$T Bloodinyourejaculate  'X%U   'X%V   'X%W   'X%X   'X%Y Urinarytractinfection  P)&Z   P)&[   P)&\   P)&]   P)&^ Othersexuallytransmissibledisease  *(_   *(`   *(a   *(b  *(c  Howmanyofyourclosestfriendsaremen?___________ `,)d Howmanyarewomen?__________ -H+f  p/,h &s\ &IG: &  Areyoucurrentlysexuallyactive?______Yes______No G Withinthepastsixmonths,howmanysexualpartnershaveyouhad?__________   Numberoftotalsexualpartners:_________  Haveyourpartnersbeen______Female______Male_______Both L Haveanysexualpartnerhadanepisodeof_Trichomoniasis_?_______Yes_______No W ЀIfyes,pleasedescribe:____________________________________________________________________________________  HaveyoueverbeentestedforHIV(AIDS)?______Yes______No  ЀIfyes,When(yr.)___________Results:___________________ReasonforTesting:___________________________ \ Haveyoueverorareyounow,engagedinahomosexualrelationship?________Yes______No g  ЀIf,yeswhen:___________________________________________ +   Haveyoueverbeeninvolvedinasexualrelationshipwithanyonewhohastoldyoutheyhadavenerealinfectionorsexuallytransmitted    disease,orAIDS?______Yes______No  l  Haveyoueverinjecteddrugsfornonmedicalreason?______Yes______No w 0  ЀIfyes,when:____________________________________________ ;  Doyoutakefrequenthotbaths,saunas,stembaths?_______Yes______No   ЀIfyes,howoften:________________________________________  |  Haveyoueverhadanyintravenousinfusionsofbloodorhaveyougivenyourselforhasanyonegivenyouintravenousinjections?______Yes @  Ѐ______No K  Doyoutakeorhaveyouevertakenanyconcentratedproductsderivedfrombloodorbloodsubstances?____Yes____No   HaveyoueverknownorassociatedwithanyonehadapositiveHIVtest(AIDSvirus)?_____Yes_____No  Haveyoueverhadsexwithapersonengagedinsexinexchangeformoneyordrugs?______Yes_____No P Haveyoueverbeentreatedordiagnosedashavinganytypeofvenerealinfection,includingSyphilis,Gonorrhea,Herpes(Type1or2), [ Chlamydia,yeastinfectionsorAIDS?_____Yes_____No  HaveyoueverbeeninasituationthatwouldgiveyouhigherriskofcomingincontactwithsexuallytransmitteddiseaseincludingAIDS?  ______Yes_____No ` Haveyoueverbeenconvictedofafelony?______Yes______NoHaveyoueverbeeninprison?______Yes_____No k$ ЀIfyes,whenandterm:___________________________________________________________________________________________ / HaveyouevertraveledoutsidetheUntiedStates?_____Yes_____No  ЀIfyes,pleaselistlocationandapproximatedate p     Location0 0 & &0< & &0<&<&0&&0D&&Dates?D&D& _____________________________________________________________________________________________________________  _____________________________________________________________________________________________________________ D! _____________________________________________________________________________________________________________ # _____________________________________________________________________________________________________________ T% Didyoucontractanydiseasesfromyourforeigntravel?______Yes______No # ' ЀIfyes,pleasedescribe:__________________________________________________________________________________________  ( Haveyoueverhadatattoo?______Yes______No <      D      L    !  T$  !d) Haveyoueverhadyourbodypierced?______Yes______No o"( * ЀIfyes,whereandwhatyear?______________________________________________________________________________________ 3# + Haveyoueverhadacupuncturedone?______Yes______No #!, ЀIfyes,whereandwhatyear?_____________________________________________________________________________________ $t"- HaveyoueverreceivedpituitaryderivedHumanGrowthHormone?______Yes______No %8#. ЀIfyes,whatyear?_________________________ C&#/ HaveyoueverreceivednonviralinactivatedfactorVIIIorfactorIXconcentrate?______Yes______No '$0 ЀIfyes,whatyear?_________________________ '%1 Haveyoueverengagedinanalintercourse?______Yes______No (H&2 @* EXPOSURE *'4  Haveyoueverservedinthemilitary?______Yes______No +T)6 ЀIfyes,when?__________________Where?__________________________________________________________________ _,*7 Haveyoueverbeenexposedto agentorangeoranyotherherbicidesorchemicalsinVietnamorelsewhere(forestservice,highway #-*8 maintenance,etc.)?______Yes______No -+9 ЀIfyes,when?__________________Where?____________________________WhatSubstance(s)?______________________ .d,:  o/(-; 2 2I 2  Pleaselistallcurrentmedicationsyouaretaking,includeoverthecountermedicationssuchas,vitamins,aspirin,antacids,laxatives,etc.) G *\d,d8 dd 8 dd  dd  dd  dd 1\3,&,&, dd , dd , dd +       Medication o(    Frequency o(    Reason o(                        w0    w0    w0             '    '   '   Howmanydaysinthepast12monthscouldyounotworkbecauseofallillness(colds,flu,accidents,surgery,etc.)?__________Days   Haveyoueverusedordoyoucurrentlyuseanyofthefollowingdrugs?_______Yes_______No g  Pleasecheckallthatapply:   *\dd dd dd dd \,&,&,dd ,dd ,dd ,dd +  w0w0 Marijuana &X0 &  Frequency     When(years)     Howused? "  "     3    3!   3" Cocaine  D#   D$   D%   D& Narcotics:Heroin,methadone,opium,codeine, ' morphine  `(   )   *   + Amphetamines  ,   -   .   / Hallucinogens  W0   W1   W2   W3 Tranquilizers#&a%D/#%&a  h4   h5   h6   h7 Antidepressants#&a%SZ#%&a  8   9   :   ; PCP#&a%Z#%&a  _<   _=   _>   _? Inhalants:_Amly_Ԁorbutylnitrate,aerosolpropellants#&a%[#%&a  p@   pA   pB   pC OvertheCounterdrugs#&a%}\#%&a  D   E   F  G  TOBACCOUSE   ~H Areyoua(pleasecheckone): !@I ______Regularcigarettesmoker______Formercigarettesmoker______Neverregularlysmokedcigarettes # K Atwhatagedidyoubeginsmokingcigarettes?___________________ $P"M Whenyousmoke(d),howmanypacksperdaydoyousmoke?__________________________ [%#N Ifyouareaformercigarettesmoker,howlonghasitbeensinceyouquit?__________________ &#O Areyoua(pleasecheckone): '`%Q _______Regularpipesmoker______Formerpipesmoker_______Neverregularlysmokedpipes /)&S Atwhatagedidyoubeginsmokingpipes?_________________________ *p(U Whenyousmoke(d),howmanypipesperdaydoyousmoke?_____________________ {+4)V Ifyouareaformerpipesmoker,howlonghasitbeensinceyouquit?________________ ?,)W  0-\ Q2 QO Q  Areyoua(pleasecheckone): G ______Regularcigarsmoker_______Formercigarsmoker_______Neverregularlysmokedcigars   Atwhatagedidyoubeginsmokingcigars?___________________  Howmanycigarsdidyousmokeregularlyperdayinthelasttwoyearsorthelasttwoyearsbeforequitting?___________ L Ifyouareaformercigarsmoker,howlonghasitbeensinceyouquit?_________________________________________ W Doyouregularlyusechewingtobaccoorsnuff?_____________________________   ALCOHOLUSE Z  Haveyoueverdrankalcoholicbeverages?_______Yes_______No %   (Ifno,thenproceedtothenextsection)    Howmuchalcoholdoyoudrinkduringanaverageweek?  f  ______Glassesofwine 5  ______Bottles/cansofbeer  v  ______Cocktailsorshotsofhardliquor(1oz) E  Duringanaverageweek,whatisthemaximumnumberofdrinks(wine,beerandcocktails,etc.)youhave  inoneday?___________________________ J Doyoutendtodrinkalone,orwithothers?______________________________ U Withinthepastyear,haveyoueverfeltbadorguiltyaboutdrinking?______Yes______No  Withinthepastyear,havepeopleannoyedyoubycriticizingyourdrinking?_______Yes______No Z Withinthepastyear,haveyoueverfeltyoushouldcutdownonyourdrinking?______Yes______No e Withinthepastyear,haveyouevertakenadrinkfirstthinginthemorningtogetridofahangoverortosteadyyournerves(eyeopener)? ) _______Yes_______No  Atwhatpointinthedaydoyoufeelyouneedadrinkmost?________________________________________ j  CAFFEINEUSE 9  Doyoudrinkcoffee?______Yes______No v  ЀIfyes,howmanycupsperday? :! Doyoudrinktea?______Yes______No E" ЀIfyes,howmanycupsperday?___________  # Doyoudrinkregularordietbeverages?_______Yes______No $ ЀIfyes,howmanycans(12oz)perday?__________________ J%  WORKHISTORY/EXPERIENCE  '  Whatisyourcurrentormostrecentoccupation?________________________________________Education:______Yrs.afterHighSchool !X) _Assc_.Degree_________BachelorDegree__________MastersDegree__________Ph.D.__________M.D._________Other_________ c" * GPA___________0 4 GPA______________0<4&4&GPA____________GPA________GPA________0!<&<&0T$!&!&0@T$!&!&'# +T$&T$& leaselistallthejobsyouhavehadinthepastfiveyearsandyourpossibleexposuretochemicals,drugsandgasses. $h"- ̀0  0&&04&&0 4&4&0 & &0< & &DatesofEmployment  NamesofDrugs,Chemicals7&#/<&<& ЀJobs/DutiesYearBeganYearEndedGassesexposeto &$0 *\d ddd @dd  dd  dd \,&,&, dd ,dd ,dd , dd +  'x%1'x%   #(%2   #(%3   #(%4   #(%5   {)4'6   {)4'7   {)4'8   {)4'9   *(:   *(;   *(<   *(=   +,)>   +,)?   +,)@   +,)A   -<+B   -<+C   -<+D  -<+E   /-G Z Z:,LO Z  Inthepastsixmonthshaveyoubeenexposedtoanyofthefollowinginyourlivingenvironment,orwhileinvolvedinhobbies?Ifyes,please  checktheappropriateitembelowandgivedatesandhowoftenyouhavebeenexposed: V *\dd dd  dd dd  dd  \,&,&,dd ,Sdd ," dd +  LL   Exposeto: B    When B    HowOften B  ToxicChemicals          Sprays  `    `    `  Fumes/Exhaust  J     J    J  Radiation            FleaPowders/Sprays   h     h     h  Lead/LeadProducts  R    R    R  Asbestos/AsbestosProducts            CleaningSolutions/Solvents  p    p   p    FAMILYHEALTHHISTORY ( * \!d ddd dd S dd " \,&,&,dd ,ydd ,dd ,dd ,dd ,dd , dd +  | |  FamilyMember  N!  EyeColor  N"  HairColor  N#  Complexion  N$  Height  N%    BodyType 'N&  ' zVision N'  Mother  8(   8)   8*   8+   8,   8-   8.  Father  /   0   1   2   3   4   5  Sister1  V6   V7   V8   V9   V:   V;   V<  Sister2  @=   @>   @?   @@   @A   @B   @C  Sister3  D   E   F   G   H   I   J  Brother1  ^K   ^L   ^M   ^N   ^O   ^P   ^Q  Brother2  HR   HS   HT   HU   HV   HW   HX  Brother3  Y   Z   [   \   ]   ^   _  Maternal f` Grandmother  *a   fb   fc   fd   fe   ff   fg  Maternal !h Grandfather  !Fi   !j   !k   !l   !m   !n   !o  Paternal 0# p Grandmother  #b!q   0# r   0# s   0# t   0# u   0# v   0# w  Paternal L%"x Grandfather  &~#y   L%"z   L%"{   L%"|   L%"}   L%"~  L%"  Howmanybloodsiblingsareinyourimmediatefamily(includingyourself)?___________ '6% Howmanymales?__________Howmanyfemales?___________ P)&  0f. Mo MRL M  Pleaselistbelowtheagesofallfamilymembers.Iftheyhavedied,pleaselisttheirageatdeathandthecauseofdeath.Pleasebeasspecificas  possible. OldAgeor NaturalCausescannotbeused,ifyoudonotknow,pleaseindicateso. V *"\#d ddd dd yZdd Zdd Zdd Zdd cdd  \!,&,&,dd ,dd ,dd ,dd +     FamilyMember ~  7Ageofliving  ~ Ageattimeofdeath  ~   Causeofdeath ~  ɇMother  D   D   D    D  Father  .    .    .    . Sister1            Sister2   L    L    L    L Sister3  6    6    6    6  Brother1                Brother2   T     T     T !    T " Brother3  > #   > $   > %   > & Maternal ' Grandmother  Z(   )   *   + Maternal  , Grandfather  v-    .    /   0   *7\8d d` dd dd 0dd dd "\#,&,&,dd ,dd ,dd ,dd +  j0j Paternal <1 Grandmother  2   <3   <4   <5 Paternal X6 Grandfather  7   X8   X9  X:  Hasanymemberofyourfamily,includingyourself,hadaproblemordefectatbirthofanyoftheirfollowingbodysystems.Pleaselistthebirth : defect,thefamilymember,whenitoccurredandanyrelevantinformation. f; *$\% dd` dd dd 0dd dd 7\8,&,&, dd ,dd ,dd ,dd , dd +  \=\   BodySystem R>    BirthDefect R?    Who R@    When RA    Circumstances RB  Bones,Muscles,Joints,Limbs  C   D   E   F   G GastrointestinalSystem  pH   pI   pJ   pK   pL NervousSystem,Brain,SpinalCord  ZM   ZN   ZO   ZP   ZQ BloodCirculatorySystem   R    S    T    U    V RespiratorySystem   "xW    "xX    "xY    "xZ    "x[ Organ,Heart,Lung,Kidney,etc.  b# \   b# ]   b# ^   b# _   b# ` Genital/Urinary  $("a   $("b   $("c   $("d   $("e Metabolic.Hormones,Enzymes,etc.  &#f   &#g   &#h   &#i   &#j Eye/Ear  j'$k   j'$l   j'$m   j'$n  j'$o Isthereanymemberofyourfamilywhohashadorcurrentlyhasalearningdisorder?_______Yes______No ")&p ЀIfyes,Pleaseexplain:_____________________________________________________________________________________ )T'q Doyouhaveanybrothersorsisterswhodiedininfancyorchildhood?________Yes_______No *(r ЀIfyes,whoandwhatwasthecause:__________________________________________________________________________ n+(s Arethereanyknowngeneticdiseasesorconditionsthatruninyourfamily?_______Yes_______No 2,)t ЀIfyes,whatarethey?_____________________________________________________________________________________ ,d*u Hasanyoneinyourfamily,includingyourself,experiencedrecurringand/orchronicphysicalsymptomsthathavebeenevaluatedbya -(+v Physician?________Yes_______No ~.+w Ifyes,pleaseindicatewhichfamilymemberinthetablebelowanddescribe: B/,x _______________________________________________________________________________________________________________ 0t-y  1.{ c'<  cbR c  KeyM=Maternal,F=Female;P=Paternal,M=Male  Pleaseindicatebyacheckmarkwhichofthefollowingmedicalproblemsyouoroneofyourfamilymembershavehad.Ifneitheryouoranyof V yourfamilymembersareaffectedbyanyofthemedicalproblemslistedbelow,pleasebesureyouputacheckmarkineachboxinthefarright  column,labeled Noone. L ,,*)\*,d  d dd dd dd dd  dd $\%,&,&, dd , dd ,dd ,dd ,wdd ,dd ,wdd ,wdd ,wdd ,,dd ,wdd ,dd ,,dd ,wdd ,wdd ,dd , dd +  ** Relative   You * ss *Mother *  ss *Father *  ss *Siblings      Grandparents %   %  Aunt %   %  Uncle %  %  Cousins @"   M  %R  %No  One * R  * *   ` *  F    F    F  F *    *M &   &M    M    P    P    M *    *P *    *M *    *P &   &M    P      F                          F   p  M   p! F   p" M   p#    #    #    #    #   F  p$    M " p%  "   %  1.Heart  Z & ЀStroke    '     (     )     *     +     ,     -     .     /     0     1     2     3     4     5     6     7 HeartAttack  v 8   v 9   v :   v ;   v <   v =   v >   v ?   v @   v A   v B   v C   v D   v E   v F   v G   v H HeartDisease  ` I   ` J   ` K   ` L   ` M   ` N   ` O   ` P   ` Q   ` R   ` S   ` T   ` U   ` V   ` W   ` X   ` Y FromBirth  &Z   &[   &\   &]   &^   &_   &`   &a   &b   &c   &d   &e   &f   &g   &h   &i   &j Other  ~k   ~l   ~m   ~n   ~o   ~p   ~q   ~r   ~s   ~t   ~u   ~v   ~w   ~x   ~y   ~z   ~{ HardingArteries  h|   h}   h~   h   h   h   h   h   h   h   h   h   h   h   h   h   h HighBloodPressure  .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .  2.Blood   Anemia  n   n   n   n   n   n   n   n   n   n   n   n   n   n   n   n   n SicklecellAnemia  4   4   4   4   4   4   4   4   4   4   4   4   4   4   4   4   4 Hemophilia                                                   OtherBleedingproblems  v   v   v   v   v   v   v   v   v   v   v   v   v   v   v   v   v Leukemia  <   <   <   <   <   <   <   <   <   <   <   <   <   <   <   <   < ImmuneDeficiency  &   &   &   &   &   &   &   &   &   &   &   &   &   &   &   &   & OtherBloodDisorder  ~    ~    ~    ~    ~     ~     ~     ~     ~     ~    ~    ~    ~    ~    ~    ~  #&a%)]#%&a  ~   3.Respiratory #&a%#%&a  !D HayFever  ,#    ,#    ,#    ,#    ,#    ,#    ,#    ,#    ,#    ,#    ,# !   ,# "   ,# #   ,# $   ,# %   ,# &   ,# ' Asthma  $!(   $!)   $!*   $!+   $!,   $!-   $!.   $!/   $!0   $!1   $!2   $!3   $!4   $!5   $!6   $!7   $!8 Emphysema  %J#9   %J#:   %J#;   %J#<   %J#=   %J#>   %J#?   %J#@   %J#A   %J#B   %J#C   %J#D   %J#E   %J#F   %J#G   %J#H   %J#I Tuberculosis#&a%'#%&a  4'$J   4'$K   4'$L   4'$M   4'$N   4'$O   4'$P   4'$Q   4'$R   4'$S   4'$T   4'$U   4'$V   4'$W   4'$X   4'$Y   4'$Z Pneumonia#&a%Կ#%&a  (%[   (%\   (%]   (%^   (%_   (%`   (%a   (%b   (%c   (%d   (%e   (%f   (%g   (%h   (%i   (%j   (%k LungCancer  )R'l   )R'm   )R'n   )R'o   )R'p   )R'q   )R'r   )R's   )R't   )R'u   )R'v   )R'w   )R'x   )R'y   )R'z   )R'{   )R'| OtherLungDisease#&a%#%&a  <+(}   <+(~   <+(   <+(   <+(   <+(   <+(   <+(   <+(   <+(   <+(   <+(   <+(   <+(   <+(   <+( #&a%#%&a  <+(  4.Gastrointestinal #&a%?#%&a  ,*   ,*   ,*   ,*   ,*   ,*   ,*   ,*   ,*   ,*   ,*   ,*   ,*   ,*   ,*   ,*   ,* Ulcerofstomach#&a%#%&a  -Z+   -Z+   -Z+   -Z+   -Z+   -Z+   -Z+   -Z+   -Z+   -Z+   -Z+   -Z+   -Z+   -Z+   -Z+   -Z+   -Z+ Duodenum#&a%g#%&a  D/,   D/,   D/,   D/,   D/,   D/,   D/,   D/,   D/,   D/,   D/,   D/,   D/,   D/,   D/,   D/, #&a%#%&a  D/, d0  dKb d   Relative  ~ You * d ss}X *Mother * d ss~X *Father * d ssX *Siblings  d   Grandparents %d  %   Aunt %d   %  Uncle %d   %  Cousins @"  d    %(   %No d  One * ( X * * D X *  r   r   r F * D X *M &D X &M  D M  D P  D P  D M * D X *P * D X *M * D X *P &D X &M  D P  D   r   8   8   8   8   8   8 F  . M  . F  . M  .   8   8   8   8   F .     M ".!  "  8! GallStones#&a%#%&a  J #   $   %   &   '   (   )   *   +   ,   -   .   /   0   1   2   3 HepatitisA#&a%#%&a   4    5    6    7    8    9    :    ;    <    =    >    ?    @    A    B    C    D HepatitisB#&a%z#%&a   h E    h F    h G    h H    h I    h J    h K    h L    h M    h N    h O    h P    h Q    h R    h S    h T    h U LiverDisease  R V   R W   R X   R Y   R Z   R [   R \   R ]   R ^   R _   R `   R a   R b   R c   R d   R e   R f ColonCancer   g    h    i    j    k    l    m    n    o    p    q    r    s    t    u    v    w UlcerativeColitis  p x   p y   p z   p {   p |   p }   p ~   p    p    p    p    p    p    p    p    p    p  _Crohn_sDisease  Z   Z   Z   Z   Z   Z   Z   Z   Z   Z   Z   Z   Z   Z   Z   Z   Z CysticFibrosis                                                                    IntestinalCancer   x    x    x    x    x    x    x    x    x    x    x    x    x    x    x    x    x RectalDisorder  b   b   b   b   b   b   b   b   b   b   b   b   b   b   b   b   b AnyotherCancerProblem  (   (   (   (   (   (   (   (   (   (   (   (   (   (   (   (   (  5.MetabolicEndocrine   Diabetes_Melitis_  h   h   h   h   h   h   h   h   h   h   h   h   h   h   h   h   h Hypoglycemia  .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   .   . ThyroidCancer                                                        ThyroidDisease  p   p   p   p   p   p   p   p   p   p   p   p   p   p   p    p!   p" Goiter  6#   6$   6%   6&   6'   6(   6)   6*   6+   6,   6-   6.   6/   60   61   62 #&a%,#%&a  63 AdrenalDisorder   4    5    6    7    8    9    :    ;    <    =    >    ?    @    A    B    C    D Hyperactivity  x!E   x!F   x!G   x!H   x!I   x!J   x!K   x!L   x!M   x!N   x!O   x!P   x!Q   x!R   x!S   x!T   x!U HormonalDisorder  "> V   "> W   "> X   "> Y   "> Z   "> [   "> \   "> ]   "> ^   "> _   "> `   "> a   "> b   "> c   "> d   "> e   "> f  6.Urinary  ($!g   ($!h   ($!i   ($!j   ($!k   ($!l   ($!m   ($!n   ($!o   ($!p   ($!q   ($!r   ($!s   ($!t   ($!u   ($!v   ($!w _Polycystic_ԀKidneyDisease  %"x   %"y   %"z   %"{   %"|   %"}   %"~   %"   %"   %"   %"   %"   %"   %"   %"   %"   %" KidneyStones#&a%#%&a  &F$   &F$   &F$   &F$   &F$   &F$   &F$   &F$   &F$   &F$   &F$   &F$   &F$   &F$   &F$   &F$   &F$ OtherKidneyDisease#&a%#%&a  0(%   0(%   0(%   0(%   0(%   0(%   0(%   0(%   0(%   0(%   0(%   0(%   0(%   0(%   0(%   0(%   0(% DiseaseofUrinaryTract#&a%#%&a  )&   )&   )&   )&   )&   )&   )&   )&   )&   )&   )&   )&   )&   )&   )&   )&   )& RectalDisorder#&a%h#%&a  *N(   *N(   *N(   *N(   *N(   *N(   *N(   *N(   *N(   *N(   *N(   *N(   *N(   *N(   *N(   *N(   *N(  7.GenitalReproductive #&a%#%&a  8,)   8,)   8,)   8,)   8,)   8,)   8,)   8,)   8,)   8,)   8,)   8,)   8,)   8,)   8,)   8,)   8,) UndescendedTesticle  -*   -*   -*   -*   -*   -*   -*   -*   -*   -*   -*   -*   -*   -*   -*   -*   -* _Hypospadiasis_  .V,   .V,   .V,   .V,   .V,   .V,   .V,   .V,   .V,   .V,   .V,   .V,   .V,   .V,   .V,   .V, #&a%#  .V,  ProstateCancer  T0-   T0-   T0-   T0-   T0-   T0-   T0-   T0-   T0-   T0-    T0-    T0-    T0-    T0-    T0-   T0-   T0- FXZ  FSK:, F   Relative  B You * d zzDv *Mother * d zzEv *Father * d zzFv *Siblings  d   Grandparents %d  %X  Aunt %d   %  Uncle %d   %  Cousins @"  d     %j<   %No d  One * j< Lv *d *  Mv *  J   J   J F *  Qv *M & Rv &M   M   P   P   M *  Wv *P *  Xv *M *  Yv *P & Zv &M   P     J                   F   M   F   M                 F      M "!  "  ! Uterine_Fibroids_  X"   X#   X$   X%   X&   X'   X(   X)   X*   X+   X,   X-   X.   X/   X0   X1   X2 OvarianCysts   3    4    5    6    7    8    9    :    ;    <    =    >    ?    @    A    B    C Canceroffemaleorgans  ^ 0 D   ^ 0 E   ^ 0 F   ^ 0 G   ^ 0 H   ^ 0 I   ^ 0 J   ^ 0 K   ^ 0 L   ^ 0 M   ^ 0 N   ^ 0 O   ^ 0 P   ^ 0 Q   ^ 0 R   ^ 0 S   ^ 0 T  8.Neurological   U    V    W    X    Y    Z    [    \    ]    ^    _    `    a    b    c    d    e Migraines  6 f   6 g   6 h   6 i   6 j   6 k   6 l   6 m   6 n   6 o   6 p   6 q   6 r   6 s   6 t   6 u   6 v Mentalretardation  t w   t x   t y   t z   t {   t |   t }   t ~   t    t    t    t    t    t    t    t    t  Senilitybeforeage50                                                   MultipleSclerosis  zL   zL   zL   zL   zL   zL   zL   zL   zL   zL   zL   zL   zL   zL   zL   zL   zL CerebralPalsy                                                   Epilepsy  R$   R$   R$   R$   R$   R$   R$   R$   R$   R$   R$   R$   R$   R$   R$   R$   R$ ConvulsiveDisorders                                                   Hydrocephalus  *   *   *   *   *   *   *   *   *   *   *   *   *   *   *   *   * DisordersoftheSpinalCord  h   h   h   h   h   h   h   h   h   h   h   h   h   h   h   h   h HuntingtonsChorea                                                        _Gaucher_ԀDisease  n@   n@   n@   n@   n@   n@   n@   n@   n@   n@   n@   n@   n@   n@   n@   n@   n@  WilsonsDisease  !   "   #   $   %   &   '   (   )   *   +   ,   -   .   /   0   1 AlzheimerDisease  F2   F3   F4   F5   F6   F7   F8   F9   F:   F;   F<   F=   F>   F?   F@   FA   FB OtherNervousSystemDisease   C    D    E    F    G    H    I    J    K    L    M    N    O    P    Q    R    S  9.MentalHealth  "T   "U   "V   "W   "X   "Y   "Z   "[   "\   "]   "^   "_   "`   "a   "b   "c   "d Schizophrenia  #\!e   #\!f   #\!g   #\!h   #\!i   #\!j   #\!k   #\!l   #\!m   #\!n   #\!o   #\!p   #\!q   #\!r   #\!s   #\!t   #\!u ManicDepressive  $"v   $"w   $"x   $"y   $"z   $"{   $"|   $"}   $"~   $"   $"   $"   $"   $"   $"   $"   $" Othermentalhealthdisorders  b&4$   b&4$   b&4$   b&4$   b&4$   b&4$   b&4$   b&4$   b&4$   b&4$   b&4$   b&4$   b&4$   b&4$   b&4$   b&4$   b&4$  10.Muscles,Bones,Joints  '% MuscularDystrophy  :) '   :) '   :) '   :) '   :) '   :) '   :) '   :) '   :) '   :) '   :) '   :) '   :) '   :) '   :) '   :) '   :) ' OtherChronicMuscleDisease  *x(   *x(   *x(   *x(   *x(   *x(   *x(   *x(   *x(   *x(   *x(   *x(   *x(   *x(   *x(   *x(   ~+P) Lupus  ,*   ,*   ,*   ,*   ,*   ,*   ,*   ,*   ,*   ,*   ,*   ,*   ,*   ,*   ,*   ,*   ,* DeformityofSpine  V.(,   V.(,   V.(,   V.(,   V.(,   V.(,   V.(,   V.(,   V.(,   V.(,   V.(,   V.(,   V.(,   V.(,   V.(,   V.(,   V.(, 6  6,US 6  Relative  d  You * d zz^ *Mother * d zz_ *Father * d zz` *Siblings  d   Grandparents %d  %.  Aunt %d  %  Uncle %d  %;/  Cousins @"  d  /  %<   %No d  One * <  f */ * :  g *  D    D    D  F * : k *M &: l &M  : M  : P  : P  : M * : q *P * : r *M * : s *P &: t &M  : P  :   D   B   B   B   B   B   B F   M   F   M     B   B   B   B   F     M "  "  B Osteoporosis      !   "   #   $   %   &   '   (   )   *   +   ,   -   .   /   0 Dwarfism  ~ 1   ~ 2   ~ 3   ~ 4   ~ 5   ~ 6   ~ 7   ~ 8   ~ 9   ~ :   ~ ;   ~ <   ~ =   ~ >   ~ ?   ~ @   ~ A Hereditylowbackdisease   XB    XC    XD    XE    XF    XG    XH    XI    XJ    XK    XL    XM    XN    XO    XP    XQ    XR Arthritis  V S   V T   V U   V V   V W   V X   V Y   V Z   V [   V \   V ]   V ^   V _   V `   V a   V b   V c Gout   0 d    0 e    0 f    0 g    0 h    0 i    0 j    0 k    0 l    0 m    0 n    0 o    0 p    0 q    0 r    0 s    0 t CongenitalDislocationhip  . u   . v   . w   . x   . y   . z   . {   . |   . }   . ~   .    .    .    .    .    .    .   11.Sight,Sound,Smell   Deafnessbeforeage60  t   t   t   t   t   t   t   t   t   t   t   t   t   t   t   t   t DeformityofEar  r   r   r   r   r   r   r   r   r   r   r   r   r   r   r   r   r Cataractsbeforeage50  L   L   L   L   L   L   L   L   L   L   L   L   L   L   L   L   L Blindness  J   J   J   J   J   J   J   J   J   J   J   J   J   J   J   J   J ColorBlindness  $   $   $   $   $   $   $   $   $   $   $   $   $   $   $   $   $ Glaucoma  "   "   "   "   "   "   "   "   "   "   "   "   "   "   "   "   " DeviatedSeptum                                                   Retinoblastoma  h   h   h   h   h   h   h   h   h   h   h   h    h    h    h    h    h Congenitalwordblindness  f   f   f   f   f   f   f   f   f   f   f   f   f   f   f   f   f  12.Skin  @  Acne  > !   > "   > #   > $   > %   > &   > '   > (   > )   > *   > +   > ,   > -   > .   > /   > 0   > 1 Eczema  !2   !3   !4   !5   !6   !7   !8   !9   !:   !;   !<   !=   !>   !?   !@   !A   !B SkinCancer  # C   # D   # E   # F   # G   # H   # I   # J   # K   # L   # M   # N   # O   # P   # Q   # R   # S PigmentationDisorder  $!T   $!U   $!V   $!W   $!X   $!Y   $!Z   $![   $!\   $!]   $!^   $!_   $!`   $!a   $!b   $!c   $!d Otherdisorderoftheskin  %\#e   %\#f   %\#g   %\#h   %\#i   %\#j   %\#k   %\#l   %\#m   %\#n   %\#o   %\#p   %\#q   %\#r   %\#s   %\#t   %\#u  13.Other  Z'$v Alcoholism  (4&w   (4&x   (4&y   (4&z   (4&{   (4&|   (4&}   (4&~   (4&   (4&   (4&   (4&   (4&   (4&   (4&   (4&   (4& DrugAbuse  2*'   2*'   2*'   2*'   2*'   2*'   2*'   2*'   2*'   2*'   2*'   2*'   2*'   2*'   2*'   2*'   2*' BreastCancer  + )   + )   + )   + )   + )   + )   + )   + )   + )   + )   + )   + )   + )   + )   + )   + )  + ) y *=\],dz,d dd dd dd dd wdd wdd wdd wwdd wwdd w,dd ,wdd wdd ,dd ,wdd wwdd wdd  dd )\*,&,&, dd , dd ,dd ,dd ,wdd ,dd ,wdd ,wdd ,wdd ,wdd ,,dd ,,dd ,,dd ,,dd ,dd ,,dd ,Xdd +  ,*,* AnyotherCancernotmentioned  -x* above?  -P+    -x*    -x*    -x*    -x*    -x*    -x*    -x*    -x*    -x*    -x*    -x*    -x*    -x*    -x*    -x*   -x*      4    <      D  .X, ,  /0- 5n  58Cdd8WU 5  ANCESTRY   HaveyoueverbeentestedasacarrierofCysticFibrosis(ifCaucasian):_______Yes_______No B Ifyes,result:________Carrier0 " 0z " &" &_________NonCarrierz &z & AreyouJewishancestry?_______Yes_______No_______Unknown 8 Ifyes,pleasecheck:__________Ashkenazi_,__________Shephardi_,_________Other  Priortoourscreening,haveyoubeentestedasacarrierofanyofthefollowingdiseases? R  TaySachs:______Yes_____NoIfyes,result:_______Carrier_______NotCarrier______Unknown *   _Gaucher_ԀDisease:______Yes_____NoIfyes,result:_______Carrier_______NotCarrier______Unknown  p  _Canavan_ԀDisease:______Yes_____NoIfyes,result:_______Carrier_______NotCarrier______Unknown  H  AreyouofBlackAncestry?______Yes_____No_____Unknown   Ifyes,priortoourscreening,haveyoubeentestedasacarrierofSickleCellDisease?______Yes______No b  Ifyes,result:______Carrier_______NotCarrier_______Unknown :  AreyouofMediterranean(GreekorItalian)ancestry?______Yes_____No X Ifyes,haveyoubeentestedasacarrierofThalassemia?______Yes______No 0 Ifyes,results:________Carrier________NotCarrier________Unknown    CHILDRENSMEDICALHISTORY  J Pleaselistbelowanychildrenyouhavefathered. *  h *(\-d,d dd dd dd dd wdd wdd wdd wwdd wwdd wwdd w,dd ,,dd ,,dd ,,dd ,dd ,dd ,Xdd X=\]&&,dd ,dd ,dd ,dd +     LivingChild | f  Ӏ(Girl/Boy) /%#T ""N /  Age |  f  DescribeanyHealthProblems |  f  AgeDiagnosed "|  "2g     z   z    z!   T"   T#   T$   T%   R&   R'   R(   R)   ,*   ,+   ,,   ,-   *.   */   *0   *1    2    3    4   5  *.\/dddd dd 7dd dd (\-&&,cdd ,Xdd ,dd ,'dd ,pdd +  N# 7N#    Children # !8 Deceased '$!9  'jAge # !:   CauseofDeath # !;  Xk  ӀAgeDiagnosed # !<  k  OtherHealthProblems # !=  k  %d#>   %d#?   %d#@   %d#A   %d#B   b'$C   b'$D   b'$E   b'$F   b'$G   (<&H   (<&I   (<&J   (<&K  (<&L    /,-S g'> gfW g  InYourOwnWords   Whydoyouwanttobeadonor? B ______________________________________________________________________________________________________  ______________________________________________________________________________________________________ 8 ______________________________________________________________________________________________________ z ______________________________________________________________________________________________________ *   ______________________________________________________________________________________________________  H  Describeyourpersonalityandcharacter:   ______________________________________________________________________________________________________ b  ______________________________________________________________________________________________________   ______________________________________________________________________________________________________ 0 ______________________________________________________________________________________________________ r ______________________________________________________________________________________________________ " ______________________________________________________________________________________________________ @ Howdoyouseeyourselfin10years,whatareyourgoals:________________________________________________________  ______________________________________________________________________________________________________  x ______________________________________________________________________________________________________ ( ______________________________________________________________________________________________________ j! ______________________________________________________________________________________________________  # Whatareyourhobbies,interests,andtalents? !8% ______________________________________________________________________________________________________ " & ______________________________________________________________________________________________________ R$!( ______________________________________________________________________________________________________ &p#* ______________________________________________________________________________________________________ ' %, Ifwecouldpassonamessagetotherecipient,whatwouldthatmessagebe? b)&. ______________________________________________________________________________________________________ +(0 ______________________________________________________________________________________________________ ,0*2 ______________________________________________________________________________________________________ r.+4   XcWX%&a J/,5 ^O ^8Cdd89f, ^  _PHYSICAL#&a%XXcW\z#   MzPHYSICALFEATURES&MEASUREMENTS  Pleasecircleoneforeachcategory  Hands:0  0r&&0r&r&Righthanded0z &&0z &z &0*&&0*&*&Lefthanded02&&02&2&0&&Ambidextrousf8&& Fingers:0 r 0r&r&Short0" &&0z " &" &0z &z &0*&&0*&*&Medium02&&02&2&0&&Long>&& Sizes0  0r&&0r&r&Neck:______0z &&0z &z &0*&&0*&*&Chest:_______0&&0&&Inseam:_______ &&    r   Waist:______0 z 0z &z &0*&&0*&*&Sleeve:_______0&&0&&Wrist::________  &&    r   Hat:_______0 z 0z &z &0*&&0*&*&Shoe:________0&&0&&  && EYES:  p    Vision:0 r 0r&r&Normal0z &&0z &z &0*&&0*&*&FarSighted02&&02&2&0&&NearSightedv H &&   Glasses:0  None0" &&0z " &" &0z &z &0*&&0*&*&Single0&&02&&02&2&0&&Bifocal0: &&TrifocalN : &: &   Astigmatism:0  Yes0" &&0z " &" &0z &z &0*&&0*&*&No& &&   AgeDiagnosed:____________Yrs.   DENTAL:     Device:0  0" &&None0z " &" &0z &z &0*&&0*&*&0&&Braces02&&02&2&0&&0: &&Retainer0$: &: &0@$"&"&Other$&$&   Reason:0  0" &&Cosmetic0" &" &0*&&0*&*&0&&Accident0&&0&&0: &&Disease0$: &: &0@$"&"&Other X :^0$&$&   Ageduringuse:___________________To______________________Yrsofage0  6&& OTHER    List:______________________________________________________________________________________________  Reason(cause): n@ ___________________________________________________________________________________________ F  FACIALFEATURES   EYES: x   Color:0 r 0r&r&Brown0" &&0z " &" &0z &z &Blue0*&&0*&*&0&&02&&02&2&Hazel0&&0: &&0": &: &Green0$"&"&~P$&$&   Shade:0 r 0r&r&Light0" &&0z " &" &0z &z &Medium0&&0&&02&&02&2&Dark0&&V( &&   Set:0 r 0r&r&Wide0" &&0z " &" &0z &z &Narrow0&&0&&02&&02&2&Average.!&&   Size:0 r 0r&r&Small0" &&0z " &" &0z &z &Average0&&0&&02&&02&2&Large"&&   Shape:0 r 0r&r&Round0" &&0z " &" &0z &z &Oval0*&&0*&*&0&&02&&02&2&Almond#&& EYEBROWS: !`%   Arc:0 r 0r&r&Flat0" &&0z " &" &0z &z &Medium0&&0&&02&&02&2&Highf"8 &&&   Thickness:0  Thin0" &&0z " &" &0z &z &Medium0&&0&&02&&02&2&Thick>#!'&&   Set:0 r 0r&r&Narrow0z &&0z &z &Average0&&0&&02&&02&2&Wide$!(&& NOSE: $")   Size:0 r 0r&r&Small0" &&0z " &" &0z &z &Medium0&&0&&02&&02&2&Large%#*&&   Width:0 r 0r&r&Narrow0z &&0z &z &Average0&&0&&02&&02&2&Wide&p$+&&   Length:0  Short0" &&0z " &" &0z &z &Average0&&0&&02&&02&2&Longv'H%,&&   Bridge:0 r 0r&r&Concave0z &&0z &z &Straight0&&0&&02&&02&2&ConvexN( &-&&   NostrilFlare:0  Small0" &&0z " &" &0z &z &Average0&&0&&02&&02&2&Thick&)&.&&   Septum:0  Thin0" &&0z " &" &0z &z &Average0&&0&&02&&02&2&Thick)'/&& Other,pleasedescribed:_________________________________________________ *(0 CHEEKBONES: ,X*2   Set:0 r 0r&r&Low0" &&0z " &" &0z &z &Average0&&0&&02&&02&2&High^-0+3&&   Prominence:0  Slight0" &&0z " &" &0z &z &Medium0&&0&&02&&02&2&Strong6.,4&& _ /-6 _'# _09 _  MOUTH: r    "  z     Size:0 r 0r&r&Small0" &&0z " &" &0z &z &Average0&&0&&02&&02&2&Large&&   Lips:0 r 0r&r&Thin0" &&0z " &" &0z &z &Average0&&0&&02&&02&2&Full&&   Turn:0 r 0r&r&Downward0z &&0z &z &Straight0&&0&&02&&02&2&Upward`&& TEETH: >   Size:0 r 0r&r&Small0" &&0z " &" &0z &z &Medium0&&0&&02&&02&2&Large&&   Set:0 r 0r&r&_Underbite_0z &&0z &z &Even0*&&0*&*&0&&02&&02&2&_Overbite_0: && " Crooked: &: &    r    "  z    *      2 CHIN:0  v H &&   Shape:0 r 0r&r&0" &&Square0z " &" &0z &z &0*&&Oval0*&*&0&&02&&02&2&RoundN &&   Prominence:0  0" &&Slight0z " &" &0z &z &0*&&Average0*&*&02&&02&2&Strong& &&   Cleft:0 r 0r&r&0" &&None0z " &" &0z &z &0*&&Slight0*&*&0&&02&&02&2&Medium0: && " Strong : &: & EARS:0   &&   Size:0 r 0r&r&0" &&Small0z " &" &0z &z &0*&&Average0*&*&02&&02&2&LargeX&&   Set:0 r 0r&r&0" &&High0z " &" &0z &z &0*&&Average0*&*&02&&02&2&Low^0&&   Angle:0 r 0r&r&0" &&Flat0z " &" &0z &z &0*&&Average0*&*&02&&02&2&Acute6&&   Lobesize:0  0" &&Small0z " &" &0z &z &0*&&Medium0*&*&02&&02&2&Large&&   Attachment:0  0" &&Attached0" &" &0*&&Detached*&*& HAIR: h   ColoratBirth0  0" &&Blond0z " &" &0z &z &0*&&Brown0*&*&0&&02&&02&2&Black0&&0: &&Red0": &: &Other______n@"&"&   ColorPresently0  0" &&Blond0z " &" &0z &z &0*&&Brown0*&*&0&&02&&02&2&Black0&&0: &&Red0": &: &Other______F"&"&   Shade:0 r 0r&r&0" &&Light0z " &" &0z &z &0*&&Medium0*&*&02&&02&2&Dark  &&   Type:0 r 0r&r&0" &&Straight0" &" &0*&&Wavy0*&*&0&&02&&02&2&Curly   : &&   Fullness:0  0" &&Balding0" &" &0*&&Thin0*&*&0&&02&&02&2&Medium0: &&Thick0": &: &"&"&   Texture:0  0" &&Fine0z " &" &0z &z &0*&&Medium0*&*&02&&02&2&Course0&&x&&    r    "  z    *      2      : HAIRLINE: V(   ForeheadSet:0  0" &&Low0z " &" &0z &z &0*&&Average0*&*&02&&02&2&High. &&   Contour:0  0" &&Straight0" &" &0*&&SlightCurve0*&*&02&&02&2&WidowPeak!&& SKIN: #   Tone:0 r 0r&r&0" &&Light0z " &" &0z &z &0*&&Medlight   2 0*&*&Medium0: &&0": &: &MedDark0@%: &: & `$"&"&   TanAbility0  0" &&None0z " &" &0z &z &0*&&Slight0*&*&0&&02&&02&2&Medium0: &&0": &: &Easyf!8%"&"&   Condition0  0" &&Oily0z " &" &0z &z &0*&&Medium0*&*&02&&02&2&Dry0&&0: &&0": &: &Combination>" &"&"&   BodyHair0  0" &&Light0z " &" &0z &z &0*&&Medium0*&*&02&&02&2&Heavy# '&& OTHERFACIALFEATURES: $")   Moles:0 r 0r&r&0" &&None0z " &" &0z &z &0*&&One0*&*&0&&02&&02&2&Several0&&0: &&Numerousv&H$+: &: &   Freckles:0  0" &&None0z " &" &0z &z &0*&&Several0*&*&0&&02&&02&2&Moderate0: &&NumerousN' %,: &: &   Dimples:0  0" &&None0z " &" &0z &z &0*&&Slight0*&*&0&&02&&02&2&Medium0: &&Deep&(%-: &: &   AdamsApple:0  0" &&Slight0z " &" &0z &z &0*&&Medium0*&*&02&&02&2&Strong(&.&& FACIALHAIR *(0   Thickness:0  0" &&Thin0z " &" &0z &z &0*&&Medium0*&*&02&&02&2&0&&Dense^,0*2&&   Shade:0 r 0r&r&0" &&Light0z " &" &0z &z &0*&&Medium0*&*&02&&02&2&0&&Dark6-+3&&     r    "  z    *  /-6 X;$ X,`0 X  PERSONALCHARACTERISTICS j  (Pleasedescribeinsomedetail)  MathSkills/Ability:______________________________________________________________________________________ 8 MechanicalSkills:_______________________________________________________________________________________ z AthleticSkills(typesports,etc.):____________________________________________________________________________ *   Whatisyourfavoritesport?________________________________________________________________________________  H  MusicalSkills:__________________________________________________________________________________________   Whatisyourfavoritetypeofmusic:_________________________________________________________________________ :  Whatlanguagesdoyouspeak:______________________________________________________________________________ X SpecialHobbies/Talents:_________________________________________________________________________________  ______________________________________________________________________________________________________ J Describeyourartisticabilities:_____________________________________________________________________________ h ̀______________________________________________________________________________________________________  Whatareyourfavoritefoods?______________________________________________________________________________ Z Whatisyourfavoritecolor?________________________________________________________________________________  x Doyoulikepets?Ifso,whichisyourFavorite?_______________________________________________________________ ( Towherewouldyoumostliketotravelandwhy? j! ______________________________________________________________________________________________________ B" ______________________________________________________________________________________________________  `$ ______________________________________________________________________________________________________ " & ______________________________________________________________________________________________________ R$!( Howwouldyoudescribeyourpersonality? &p#* ______________________________________________________________________________________________________ &H$+ ______________________________________________________________________________________________________ (%- ______________________________________________________________________________________________________ :*'/ ______________________________________________________________________________________________________ +X)1   0 r    "  z    *    r&r& ,______________________________________________________________________________________________________ -+3    r    J/,5 Vo0 Va` V  wPROCREATIVECRYOBANK,LLC j      Ӏ CONFIDENTIAL  ` DONORPERSONALINFORMATION󀀀  LASTNAME:______________________________________FIRST:___________________________________M:_______ .   YwhADDRESS:__________________________________________CITY:___________________________________________  L  ZIP:__________________________STATE:________________DATEOFBIRTH:________________________________   SOCIALSECURITY#:______________________________________RACE:_____________________________________ >       a     i      q    ! (_Cauc_,black,etc)   HOMEPHONE:__(_______)_____________________WORKPHONE:__(_______)_______________________________ 4 ЀOCCUPATION:__________________________________________EDUCATION:_________YRS_ԀAFTERHIGHSCHOOL v RELIGION:________________________________________MARRIED:_____YES_____NO,IFYES,_______YRS_ & SPOUSENAME:_____________________________________________________ D ETHNICORIGINOFMOTHERSFAMILY:  ___________________________________________________________________ ^ ETHNICORIGINOFFATHERSFAMILY: | ____________________________________________________________________ T AREYOUADOPTED?_______YES_______NOYOURBLOODTYPE:____________RH:__________   HEIGHT:򀀀FeetInches󀀀WEIGHT:򀀀lbs. !   # I,___________________________________________,acknowledgethatIhavereadandfullyunderstandtheDonor ~# ' Medical/HistoryQuestionnaire.Irepresentthatallinformationprovidedistrueandcomplete. V$!( ____________________________________________________0 q 0qp&qp&_____________________________________&L$+p&p& Signature0  0a p& p&0 ap&ap&0 p& p&0i p& p&0ip&ip&0p&p&0qp&p&0qp&qp&Date'$%,p&p&      a    N/,5 Ї @  @  @ PROCREATIVECRYOBANK.LLC   DONORCONSENTDOCUMENT    I,______________________________________________________voluntarilyandasanindependentlycontractingfreeagent  herebygivemypermissiontoProcreativeCryoBank,LLC(PCB),toacquireandtestmyblood,urineandspermcells.Also,I z amaware,thatifaccepted,PCBwillacquire,testandsellmyspermcells.IunderstandPCBwillmakethemavailableforsale R  fortheuseofinfertilitypurposes.Iunderstandthatifacceptedinthiscapacity,everyreasonableeffortwillbemadetonever *   disclosemyidentityasadonorwithoutmypermissionnortorevealtheidentityoftherecipienttomeunlesstherecipientandI  p  bothagree.Iunderstandanexceptionmayberequiredbylegalorjudicialprocess.  H  IagreethatIwillbecompensatedformytime.Afterthescreeningproceduresandmyfirst6deposits,thatarerequiredbyPCB   arecompleted,Iwillbepaid$50.00peradequatespecimen.IamawarePCBwillholdback$50.00outofmyfirst6deposits,a b  totalof$300.00willbepaidtomewhenIhavecompletedthescreeningprocessandthequarantineperiodof180days.Iagree :  thatPCBmayrequiredmetodonateatleasttwicepermonthor24donationpercalendaryear.IfurtheragreethatIwill   participateinPCBdonorprogramforatleast2yearsunlessIamdisqualified.IfIleavetheprogrambefore2yearsIwillgive X PCBwrittennotice.Also,ifPCBfeelsthereasonforleavingtheprogramisnotjustifiable,PCBmayvoidthiscontractandI 0 giveupallrights.Onceacceptedintotheprogram,IamawareIwillberequiredtohavetheinfectiousdiseasescreening  repeatedevery3months.DuringthistimePCBwillholdmymoneyuntilallrequiredtestsbyPCBhavebeencompletedand r resultsarenegative.Iunderstandthatifanyofthetest(s)arepositiveandthespecimen(s)Ihavedonatedcannotbeused,Iwill J notbepaidforthosedonation(s).IfurtherunderstandifIreceivemorethan$600.00percalendaryear,thisfeewillbereported " totheIRSfortaxpurposesandIwillberesponsibleforallfederalandstatetaxliabilities. h IacknowledgethatIhavereadandfullyunderstandthisinformedconsentdocument,andhavehadallquestionsandconcerns  fullyansweredbythestaffofProcreativeCryoBank,LLC.  Thisinformedconsentandauthorizationdatedthis______dayof______________20____,willbegovernedbythelawsof 2 theStateofMissouri.  x ___________________________________________________________________________________________________ ( SignatureofDonor0 a 0 ap&ap&0 p& p&0i p& p&0ip&ip&0p&p&0qp&p&0qp&qp&0!p&p&Date !p&!p& ____________________________________________________________________________________________________ B" ProcreativeCryoBank,LLCemployee0  (Witness)0 p& p&0p&p&0qp&p&0qp&qp&0!p&p&Date #!p&!p&      a    I,__________________________________(wifeofdonor),herebyconsenttomyhusbandparticipatinginProcreative " & CryoBank,LLC(PCB),SemenDonorProgram.IfullyunderstandhissemenwillbetestedandsoldbyPCBforinfertility z# ' purposes.Iw