Donor Number: 240315

Health History:

Have you ever been pregnant? No

Do you have any children? No

Have you ever placed a child up for adoption? No

Any history of infertility in your family? No

Deliveries: N/A

#1: Date of delivery: Months trying to conceive:

Birth Weight: At how many weeks/days did you deliver? wks days

#2: Date of delivery: Months trying to conceive:

Birth Weight: At how many weeks/days did you deliver? wks days

#3: Date of delivery: Months trying to conceive:

Birth Weight: At how many weeks/days did you deliver? wks days

Date of last Pap Smear: Were the results normal? Never had one.

Are you currently using birth control? No

Do you have a regular monthly menstrual cycle (every 21-35 days)? Yes

Do you smoke? No

Do you drink alcoholic beverages? Yes

If yes, how often? 2-3 times a month

Do you use recreational drugs? No

Are you currently taking any medications? No

Please describe any medical problems you have had: I have asthma from having RSV as an infant. I also had a heart arrhythmia that was fixed with a non invasive surgery.

Have you or any of your biological relatives (including your parents, siblings, aunts, uncle, cousins and children) suffered from: (if yes, explain)

Physical birth defects? No

Down Syndrome? No

Mental Retardation? No

Ovarian Cysts? No

Uterine Fibroids? No

Asthma? Yes - I have it from having RSV as a child.

Heart disease? No

Heart attack? No

Coronary artery disease? No

High blood pressure? No

Arrhythmia? No

High cholesterol? No

Atherosclerosis? No

Diabetes? No

Thyroid problems? No

Blood clotting disorder? No

Anemia? No

Learning disability/ies? No

Blindness? No

Hearing loss? Yes - Grandparents from old age.

Osteoporosis? No

Dwarfism? No

Huntington’s disease? No

Chronic heartburn? No

Alzheimer’s disease? No

Parkinson’s disease? No

Cerebral Palsy? No

Muscular Dystrophy? No

Seizure Disorder/Epilepsy? No

Cystic Fibrosis? No

Kidney disease? No

Any type of cancer? No

Seriously overweight? No

Multiple birthmarks? No

Alcoholism/heavy alcohol use? No

Recreational or prescription drug abuse? No

Been treated by a psychiatrist? No

Depression? Yes - Mother

Schizophrenia? No

Suicide attempt? No

Other mental illnesses? No