Donor Number: 240502

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 - My mom struggled to have kids for 13 years. It’s likely related to her unusual uterine conditions (she started menstruating very young, and had heavily irregular cycles).

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? Have never had one.

Are you currently using birth control? Yes - Transdermal patch- xulane. About a year.

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

Do you smoke? No

Do you drink alcoholic beverages? No

Do you use recreational drugs? No

Are you currently taking any medications? No

Please describe any medical problems you have had: Eczema from my dad’s side. It is not a disease, but it is hereditary and mildly irritating.

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? No

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? No

Osteoporosis? No

Dwarfism? No

Huntington’s disease? No

Chronic heartburn? No

Alzheimer’s disease? Yes -

Parkinson’s disease? No

Cerebral Palsy? Yes - My uncle is mentally handicapped with cerebral palsy. Family has mentioned that it’s related to him not getting enough oxygen at birth.

Muscular Dystrophy? No

Seizure Disorder/Epilepsy? No

Cystic Fibrosis? No

Kidney disease? No

Any type of cancer? Yes - My mom’s had it two or three times, once on her thyroid and one or two times in her uterus/cervix. Her mom, a heavy smoker, died of lung cancer. My dad’s dad had cancer on his eyelid but got it removed in time.

Seriously overweight? No

Multiple birthmarks? No

Alcoholism/heavy alcohol use? Yes - My maternal grandma was a rarely sober after 4pm, and my paternal uncle was a once-in-a-blue-moon binge-till-you-OD drinker. He is now sober. I hear that my great-grandparents and further had their fair share of alcoholism too. On the bright side, my dad and his mom drink very responsibly, and my mom doesn’t drink at all.

Recreational or prescription drug abuse? No

Been treated by a psychiatrist? No

Depression? No

Schizophrenia? No

Suicide attempt? No

Other mental illnesses? No