EMBRYO DONOR FAMILY INFORMATION
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1 EMBRYO DONOR FAMILY INFORMATION Please type or use black ink for the information on this sheet so the adoptive family may have some insight into the background of the child that may result from your frozen embryos. Please DO NOT list any identifying information such as a name. HUSBAND PHYSICAL CHARACTERISTICS: Height: Weight: Race (Circle all that apply): Caucasian, Black, American Indian, Asian, Hispanic, Other: Family Ethnicity (Circle all that apply): English, Irish, Italian, Greek, Spanish, Swedish, German, Chinese, Japanese, Other: Drug Allergies: Are You a Twin?: Yes: (identical, fraternal) No: Hands: Right Handed, Left Handed, Ambidextrous Hair (circle most appropriate from each line): Color at Birth: Blonde, Brown, Black, Red, other: Present Color: Blonde, Brown, Black, Red, other: Shade: Light, Medium, Dark Texture: Wavy, Straight, Curly Body: Thin, Medium, Thick Eye Color: Blue, Green, Hazel, Brown, Black, other: Complexion: Fair, Medium, Dark Body Build: Small, Medium, Large MEDICAL HISTORY: YES_ NO Acne Bleeding Tendency or Problem Thyroid Disease Prostrate Disease Diabetes High Blood Pressure Heart Problems Hepatitis Mitral Valve Prolapse Kidney Disease Liver Disease Urinary Tract Infections Blood Clots in Legs or Lungs Psychological or Emotional Problems Depression Victim of Sexual Abuse Consume more than 7 alcoholic drinks/week
2 If you answered YES to any of the questions, please explain details: Have you ever been hospitalized in the past? YES NO If YES DATE REASON Please list all previous surgical procedures: DATE TYPE OF SURGERY COMPLICATIONS GENETIC / FAMILY HISTORY: Do any members of your immediate family or extended family (cousins, aunts, uncles, grandparents) have: (Please circle all that apply to your family) Down s Syndrome Alzheimer s Tay Sach Mental Illness Thalassemia Depression Schizophrenia Diabetes Huntington s Disease Arthritis Hemophilia Cystic Fibrosis Muscular Dystrophy Marfan s Syndrome Neurofibromatosis Hereditary Anemia Von Recklinghausen s Disease Sickle Cell Anemia Fragile X Syndrome Mental Retardation Congenital Heart Disease Heart Attack before age 50 Please list type of relationship to each of the above:
3 EDUCATION: Highest Educational Degree Obtained (Please circle One): Middle School, High School, College, Graduate School, Post Graduate School Major: Occupation: HOBBIES AND INTERESTS: Personal Favorites: Color: Food: Music / Band / Singer: Movie: Song: Hobbies: Athletic Enjoyments: TALENTS: Sports Played: Yes: No: If yes, what sport(s)?: Musical Instrument Played?: Yes: No: If yes, what instrument(s): Artistic Talents (circle all that apply): Painting, Drawing, Sculpting, Carving, Singing, Songwriting, Dancing, Writing, Acting, Other: WIFE PHYSICAL CHARACTERISTICS: Height: Weight: Race (Circle all that apply): Caucasian, Black, American Indian, Asian, Hispanic, Other: Family Ethnicity (Circle all that apply): English, Irish, Italian, Greek, Spanish, Swedish, German, Chinese, Japanese, Other: Drug Allergies: Are You A Twin? Yes: (identical, faternal) No: Hands: Right Handed, Left Handed, Ambidextrous Hair (circle most appropriate from each lines: Color at Birth: Blonde, Brown, Black, Red, Other: Present Color: Blonde, Brown, Black, Red, Other: Shade: Light, Medium, Dark Texture: Wavy, Straight, Curly Body: Thin, Medium, Thick Eye Color: Blue, Green, Hazel, Brown, Black, other: Complexion: Fair, Medium, Dark Body Build: Small, Medium, Large
4 MEDICAL HISTORY: YES NO Acne Bleeding Tendency or Problem Breast Discharge Thyroid Disease Diabetes High Blood Pressure Heart Problems Hepatitis Mitral Valve Prolapse Kidney Disease Liver Disease Urinary Tract Infections Blood Clots in Legs or Lungs Psychological or Emotional Problems Depression Victim of Sexual Abuse Consume more than 7 alcoholic drinks/week If you answered YES to any of the questions, please explain details: Have you ever been hospitalized in the past? YES NO If YES DATE REASON Please list all previous surgical procedures: DATE TYPE OF SURGERY COMPLICATIONS GENETIC / FAMILY HISTORY: Do any members of you immediate family or extended family (cousins, aunts, uncles, grandparents) have: (Please circle all that apply to your family)
5 Down s Syndrome Alzheimer s Tay Sach Mental Illness Thalassemia Depression Schizophrenia Diabetes Huntington s Disease Arthritis Hemophilia Marfan s Syndrome Muscular Dystophy Cystic Fibrosis Neurofibromatosis Hereditary Anemia Von Recklinghausen s Disease Sickle Cell Anemia Fragile X Syndrome Mental Retardation Congenital Heart Disease Heart Attack before age 50 Please list type of relationship to each of the above: EDUCATION: Highest Educational Degree Obtained (Please Circle One): Middle School, High School, College, Graduate School, Post Graduate School Major: Occupation: HOBBIES AND INTERESTS: Personal Favorites: Color: Food: Music / Band / Singer: Song: Hobbies: Athletic Enjoyments: TALENTS: Sports Played: Yes: No: If yes, what sport(s)?: Musical Instrument(s) Played?: Yes: No: Artistic Talents (Circle all that apply): Painting, Drawing, Sculpting, Carving, Singing, Composing Songs, Dancing, Writing, Acting, Other:
6 NEDC USE ONLY: (TO BE KEPT CONFIDENTIAL) Wife s Name: Husband s Name: Address: Home Phone #: Work Phone #: Cell Phone #: Address: Date Received by NEDC: Donor # assigned: Date Embryos Received: Date Matched: Date Transferred: Pregnancy Result:
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Welcome to Dr Jamie Italiane-DeCubellis s office Thank you for choosing our healthcare team for your dental needs. Our goal is to make your experience here pleasant and to provide you with high-quality