QI·`nn - Nation Wide Egg Donation

Transcription

Jan
21 201
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NWED
:OlPM
2088JS80
I2
p .. 1
QI·'nn~
011209-1 Quinne
DONOR NUMBE~
Donation Applicati n form
Page
.
Blood
Type ifl known: '
Height:
LNo
Recent weight . sig~in?-_Yes
What was your
eight at age 21? IWb
•
If yes __
tli~ best describe you below:
~es
ISmall -
Ambidextrous
Medium
I
Large
Complexion:
Vjry Fair· Fair l.!:ight - Medium
Tan ability:
N,
e
Slight.
Oily
Medium
(Medium}
Eye Color:
.r
.
Conditionofy
Have y<>uh.d
I
u'rteeth:
It.8rown
Oar1<Brown
Fine· [Medi~m
Family: __
L Medium J
or
Yes
Fair
.
+--.
orth"'\O"ticwork? LVe.
Hearing (wltho t Corrective aids):
Poor
Fair
Vision (withe
Poor
IFair
cckective lenses):
Yes . ~No
Green
Shape:·
BlOnd~
Hazel
Round
Light BfiOwn
Oval [Almond]
. Medium Brown
1 Coarse
.k.
Fullness:
Thick
No
I
I GoocH
-
1
-_Nr
If yes, at ~hatage?
excellent
GOOillEJellent
P.rescription (I known):-\.COo
'1
Nation Wide Egg Donation (208) 895-8667
[Thin - Medium]
Large
.
- GOod~xcenent
0.--"-.
"1periocontal
I ~ark
Medium BlOnde··
If yes, atwhatage __
Poor·
__
Ebd y
I
Size: . Smal~ (Averagel'Large
Bardtl~~in
I Features: . Small
DarK Brown
Combination
DrY
Hair Texture:
Yir:-. _Yes~No
Body and Fac
BrJ.n
Red
1 straight I
. es~No
Olive . Light
I.
I Dimples?
q9ht Biondi]·
Dark Brown
Wavy
r
Freckle
WtdeEye
Natural Hair C
Very Large
~
BroWn
Eye sat: Narr
Baldness:
·_Ibs loss/gain(circle one)
..
Left Handed
Skin Conditio
_+_
Date of Birthj' -L'-.1.~.La:t
lU> lbs. ..
Weight:
9
www.nationwideeggdonation.com
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21 201~ 7:01PM
Jan
I
NWED
20889580 2
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011209-1 Quinne
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Other SkillsihobJie~alen1s1interests do you have (Le. :riting, readinJ. ability to do games orlcrossword puzzles.
handcrafts)? D~cribe:' 1I»1c. (j2.Q;6VJOI?J') pun! f?.S • cBAfl'""ll>l2.o.lpc:;r:;
I:
Current OCCUpaJio
1~J2-.
I:?.fbl0tJe.B.
v
How Idng have you been at your current job?
\e
1AOtf!l\S
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HABITS:
Exercise Habits· ~None
Your diet is:
-:J'
Do you have
_Occasional
--:l.-Regular
I
...lL.-Non-vegetarian
iegetarian
dietary restrictions'? ..••
N~Q~
I
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Your diet is:
CWod ~'!'\O~I~I\rlaverag~
excellent
-"I__
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.
poor
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2
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3
4
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YOUR CHILDREN
Aae
I
Sex
I I
j I
Eve color
Hair Color
I
Frame size
I I
I "
Grade in schoo
Personalitv
I I
Artistic abilitv I
Inte/!iaence
I
Distinauishina dharacteristics
Wears eve alas$es
Discioline orob~ms
Anv medicationl I
Dvslexia
I
Readina difficudies
SDeech difficultiesl
Anv soecial ser1lices at school
Seen bv Social ~dr1<:erlcsvchiatrist
I
.
Grade function I level:
Normal I Abo~1 Below Averaae
1_
Typ$ of Exercise:
----
r
21 201
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7:01PM
2088958072
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I
011209-1 Quinne
OON()Jt NUMBER
DQn~ti.e>rI Appli~ " n form '.
. bloJI siblings
I ar~.' in yo~r
.. ' immediat~
. . '.family (induding
.
Ho~ ma~'y
Number of BrOtlil ers
'1
l
2.
.
I
I
Do
I'·
'
•
,
.Number of Matem~l Uncles _-1...
Number of Maternal Aunts
Number of Pat' mal Aunts
.)
I
"
"yes,whatwasthecause?
·lI!eihere
.
I,.r~of~Our
Ony
If yes,
lease explain
.
I····
.
. Number of Paternal UncleS '~---L
you have any L'hOlS or siste rs that died ininl;lncy or childhood~ __
.
-..lLti.-""--~
yourself ~nd half siblings}?
Number of Sisters
.
Pagt:j12'
Yes
_
-LNo
~--------------------------------
family wnh a history. of leaming disabnnies or eutlsm?
.
.
'.
I
-yes
•
~NO
.
'.
.
.
Describe genetic lamily members according to the following characteristics. Use natural eye and hair.,color; fair/dark, etc.'
compfexion. Ifhe~ are deceased, please list cause of death. Please do not put "naturar as a cause of death. "
unknown, writ~ ·uhknown"
.'Ic~r
~uk, a~
I I
Sister(s)
Br.other(s)
tiair
':fAue'
-.
I ..
'
~~tl
~~(,
Mottler:
Matemal
Grarldmother
Materanl
Grandfather
Paternal
Grahdmother
Paternal
Grandfilther'
Weight
f'(l\p;.
5-I~.
·l2.5'
Rll~
{P1-111
·Y=fO Med\urt1 Ci~,\€r\c:(lnee~. 2.l.P
~'1fti~
~I-O·
\~
1~
Medll)m
··D(l~.
fJl-2" . 130
~\.e
Ftt\~
1,'-0' .. UX>
I I .
Father
.~
~~
~11
.
··Bone
Structure
Medi'f
B\\lf.
~Vl~~
I
~\Ct"Id
faIR..
fu~
, (p1_0'
'\1ijh~\
('Y\«1iom
.. Causeof
death
2-.0
,~~
S'3
.
-Avdir
53
"BaVL~R
ieo M-edt\lm'
TeOO\~
83
SiewP-e.
fS'1O
l)t'ljqH)WY\
~O
:
VI
\i~\'.V)O~
...
. I
Age at time
of death
IB
!:mderl- '.
l'~\tea;~
Me.divtf1 M~\co.'
1~'ntefL
5 -<0" \00 M~'
1
Age if
lima
rJ.ed\l]1'll
ed-i VOl
f,\tle. B~wn b~W. '6'-2" \100 .M5mt1ll
B\ue. Reel
OcC;Upjitionl, .'
Education
. Height ..
Complexion·
Color
,
I
.
Jan
21 201
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Nt..JED
2088958072
011209-1 Quinne
Aneihla
I
Sickle-Cell Anemia
I
Facioi' V Lelden·
tflrombpphilia {Blood
clots or strOkes
I
· Hemopflllla or other,
BleedinglClolting
Disoraers sucti as
Von Willebrand's
Disease
Immune DeflCie
· Leukemia
Lymphcma or
· Swollen Lymph
· N es
HIV
I
Thalassemia
NoooJ
p. . arteritis
Asthma·
Ha· Fever
Em
sema
Tuberculosis
Prieumonia
Alpha-1 antitrypsin1
Disorder
Blood inS
Other L
I
Disease
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__P~M__ ~NWED
2088958072
DONOR NUMBER
Donation Application Fcnn
p.7
011209-1 Quinne
PagelS
'.
Father
Mother
Self
None
. -.
-
Sib~ng
Grandparents
AunV
Uncle
'.
.:
~
".
Explanation (v.Nch side Of family.
age of onset. etc.)
Cousin
".'"
-'
..
-..
"
. Appendicitis
Ulcer of Stomach or
Duodenum
Gallstones
Heoatitis A,B or C
Cirrhosis
of !he Uver
Other liver
Disea&e
Ulcerative CoVtis
Crohml Disease
PYloric Stenosis
Multiple Polyps of the
Colcn
Rectal Dborder
Inftammatory Bowel
Disease
Any other problem of
the diaesUve sYStem
r:M~i;l~t1h.j;·;
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Diabetes requiring
insulin theraDv
Diabetes not
requlring insulin
!heraov'
.
Childhood Diabetes
Thvrold disorder
Goiter
Hvooalvcemla
Adrenal DysfLnction
or Disorder
Phenyl Ketonuria
(PKU) or inherited
Metabolsm Disorder
Obesitv
Dwarfism
.
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Jan
21 201J 7:05PM
NWED
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p.8
011209-1 Quinne
Kid -
Problems
Polycystic Kidney
- Disease
Other disease! defect
- of urinary tra<:t
(urettwa, bladder.
ureter)
I
Hermaphrod~lsml
Ambiguous Genitals
- Hypospadias or
undescended testicle Uterine FlbrOids
Ovarian
Cysts or
Ru tured
Limps or Cysts In
Breast Of Dischar e
2 or more
MiScama
s
stillborn
Premature
~-~~n~~m~e-------t-----1r-----t-------t-------+-------+-------~~--~--~--~------------~------~~=
Death of I! newborn
infant
Childhood death
Birth defects
Infertii
PremalUte Birth
..
-
I
Jan 21 2012 7:06PM
NWED
2088958072
p.9
011209-1 Quinne
None
Sibling
Father
Mother
Self
::-
:;
t •••
Grandoarents
Aunt!
Uncle
Cousin
explanation (which side of ramily,
aoe of onset etc.)
,''J
',
Mklralnes
Mental retardation
Senility or Mental
Deterioration before
aae50
MuHiDle Sclerosis
Cerebral Palsv
Neurofibromatosis
EDileDSV I Seizures
Attentloo Deficit
~~,!derJ ..
MYPIIractiviN
Autism I AsDeroer'S
Alzheimer's
DiSeaselDementla
Hvdroceohalus
Tuberous
Sclerosis
Parkinson's
Disease
CreutzfBIdt-Jakob
Disease
Scoliosis
MYasthenia Gravis
HL.nII~ton·S or
IMlson 6 DIsease
Tourette's syndrome
Other diseases oftoo
nervous system
~'u.
~'~L~,·'~:,.>
,X:, ,:..';"J.'::..,';:, ~~,"'.'
". ··:r .. ' •.
:;:,6 '" -:"
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Anxiety I Panic
Attacks
Anorexia /
Bulemialother
disorders
eating
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Jan
21 2012 7:06PM
------------------------------
NWED
2088958072
011209-1 Quinne
Mother
~If
De
Sibling
Father
AunV
Uncle
Cousin
siar!
Schizo
renia
· Manic Depressive
Bi
r Disorder'·
or
".
Other merltal health
disorcler requiring
hospitalization
.Suicide Atte~ts
.Other menIal health "
problems that
warranted counseling
tease list
..
Other .Chronic
Muscle Disease
O&teosenesis
·imperfecta (brittle
bone disease)
L08S of Mu$de
Coordination
Os
«-.
rome
:ArtIYltIs .
".R!leumatoid or
Juvenile Arthritis
Spinal Muscular
Atro h
Hereditary Low Back
·Disorder or DefomJity
of
"
.
'Reiter's
Disease
asthenia Gravis
.
.'
~
.
p.lO
Jan 21 2012
7:08PM
NWED
2088958072
DONOR NUMBER
Donation Application Form
.
p. 11
011209-1 Quinne
Page 19
':.~':
,~':. ,'.-:
.-."
.
None
Self
Mother
Father
Sibling
GrandPIWents
Aunll
Uncle
Cousin
Explanation (v.1'lIch side of fam~y,
age of onset, etc.)
Metabolic Bone
Disease (be more
sDeClflc)
Lupus (systemic
lupus erythematosis
-SLEI.
.
..' b' .
......
Deafness before age
60
Defofmity of the ear
cataracts before age
50
BlIndness
COlOr Blindness
8ewre Mvooia
Glaucoma
Retinoblastoma
Retinitis Piamentosa
Oe\Iiated SeDtum
ArroJ ather Sensory
Disorder
...".... ':"".:
...
'
...
:-:
.
Acne
Albinism
Eczema
Pigmentation
Disorders
PsQt"iasls
Neurofibromatosis
.
"
Jan
21 2012 7:08PM
Donation Application
NWED
DONOR NUMBER
Form
None'
2088958072
Self·
Mother'
. Father
011209-1 Quinne
AumJ
Sibling
p.12
.Page 20
Cousin.
Uncle
Explanation (which side of fMlily,
age of onset, etc.)
other diSDJUer5 Of
the skin
· Infectious Skin
Disease
More tI1an 5 purple- .
or colfee- co! ored
spota on skin (size of
rter or lar r
Cleft
. I Palate
Congenital Hip
. Pro b4 em 5 .
· Club Feet
Heart Defect
Hearin
Problems
Microce al
Holoprosencehpaly
· a singl(:i=-Iobed braiin
-
.. structure and severa'
· sku~'ancUactal
.
defects
. Other .
AIcohois,;,
Drug abuse, Misuse
or Addiction
Premature
degeneration of any
o' an s tern"
.'
Airy other condiiion
not mentioned above
Explain: ~
-:-
-'--'-
---:-_----,
-,.--'-
_
Jan
21 2012 7:09PM
NWED
2088958072
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Page21
011209-1 Quinne
DONOR NUMBER
DonationApplicationForm
p.13
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Ethnic origin (e.9" French, Irish)
Mother:
~:
Jt0tign - 112.\$hl--
--,-
Father.
£rz.et1cb~-.,.l"Gz"t¥s.:.r;:.r;m.:.uo:l.an'-'--
_
Check all that apply for your ancestors:
African American
Eastern European (Ashkenazi) Jewish
Mediterranean (Greek. Italian)
Hispanic'
Indian (from India)
Southeast Asian (Laotian, Vietnamese. Cambodian)
French canadtan
Cajun
(MGM~atemal
Mother
Father
MGM
MGF
-Mother-Father-MGM-MGF-PGM-PGF
IMother
Father2MGM=MGF
_Mother_Father_MGM_MGF_PGM_PGF
Mother
Father
MGM'
MGF
.
Mother
Father
MGM
MGF
Mother
Father
MGM
MGF
-Mother-Father-MGM-MGF-PGM-PGF
-
-
-
-
PGM
PGF·
PGM-
PGF
PGM
PaM
PGM
PGF
PGF
PGF
-
-
Grandmother, MGF=MatemalGrandfather; PGM=Patemal Grandmother, PGF=Patemal Grandfather)
Have you or anyone in your family ever been tested positive as a carrier or had any of any of the following diseases?
Blooms Syndrome
Canavan
Cystic Fibrosis
Fabry Disease
Familial Dysautonomia
Familial Mediterranean Fever
Fanconi Anemia Grp, C:
Gaucher
Niemann-Pick type A
Mucolipidosis type IV
SickleCelJ
Tay-Sachs
Thalassemia
No
No
No
No
No
No
No
No
No
No
No
No
No
If yes:
If yes:
If yes:
If yes:
If yes:
If yes:
If yes:
If yes:
If yes:
If yes:
If yes:
Iryes:
If yes: .
_
__
_
__
disease __
carrier __
negative
disease _carrier
__
negative
disease __
carrier __
negative
disease __
carrier __
negative
disease _carrier
__
negative
disease __
carrier __
negative
disease _carrier
_negative
disease __
carrier __
negative
disease __
carrier __
negative
disease _carrier
_. _negative
disease __
carrier __
negative
disease _carrier
_negative
disease _carrier
__
negative
_
Is there anything else we shoukl know about your family?
__
__
unknown
unknown
_unknown
__
unknown
__
unknown
__
unknown
_unknown
__
unknown
__
unknown
~unknown
_unknown
_unknown
__
unknown
Jan
21 2012 7:10PM
NWED
2088958072
DONOR NUMBER.
Donation Application Form .
fa
. Page-22·
011209-1 Quinne
In your own words, describe your personality, temperament,
and .
character: I.AM CAkM .AND c.ol,1.{;f.ffiD·.ArJD "fliV/1PNGlAtfAta>,
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What physiCal; art!stic, inteHectual or social abilities do you feel best about:
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What are your present and future career goals:
,
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your present and future personat goals:
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List the 3 achievements
you are most proud of:
.
212012
Jan
7:10PM
NWED
2088958072
011209-1 Quinne
DONOR NUMBER
Page 23
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What is your favorite movie?
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What is your favorite book?
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What is your favorite color?
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What is your favorite food?
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What is one of your most memorable moments and why?
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DONOR NUMBER
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Please orovide the follOWlna in f ormation a b out your f amllY:
Intellectual/Academic Achievements
r
t.
Mother
<.J
Father
Sisters
011209-1 Quinne
Page25
Artistic Achievements
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on a message to the recipient(s) of your eggs or sperm, what would that message
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If you could write a message to the child born through your participation as an egg or sperm donor for when he/she turns
18 years old, what would you tell himlher?

QI·`nn - Nation Wide Egg Donation

Transcription

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