Donor Number: 240404

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? Yes- Mother had a miscarriage

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? Results were normal on 09/02/2023

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 - Maybe one every few weeks. Hardly ever and it’s usually a glass of wine.

Do you use recreational drugs? No

Are you currently taking any medications? No

Please describe any medical problems you have had: None

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? Yes - Mother

Uterine Fibroids? No

Asthma? No

Heart disease? No

Heart attack? No

Coronary artery disease? No

High blood pressure? No

Arrhythmia? No

High cholesterol? Yes - Paternal Grandfather

Atherosclerosis? No

Diabetes? No

Thyroid problems? Yes - Maternal Grandmother

Blood clotting disorder? No

Anemia? No

Learning disability/ies? No

Blindness? No

Hearing loss? No

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? Yes - Paternal Grandmother and Grandfather

Seriously overweight? No

Multiple birthmarks? No

Alcoholism/heavy alcohol use? No

Recreational or prescription drug abuse? No

Been treated by a psychiatrist? Yes - Situation anxiety. I had some family troubles and lost a few family members. But I am stable and do no need to go on a regular basis.

Depression? No

Schizophrenia? No

Suicide attempt? No

Other mental illnesses? No