EXPANDED PROFILE : Eve722
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- Noel Allison
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1 EPANDED PROFILE : Eve722
2 SOME INTERESTING FACTS ABOUT: YOUR STAR SIGN: WHAT DO YOU CONSIDER AS YOUR BEST FACIAL FEATURE: WHAT DO YOU CONSIDER TO BE YOUR BEST PHYSICAL FEATURE: HOW WOULD YOU DESCRIBE YOUR SMILE: HOW WOULD YOU DESCRIBE YOUR LAUGH: WHICH ACTRESS OR FAMOUS PERSON YOU THINK YOU RESEMBLE: Eve722 Scorpio Eyes Collarbone Engaging Infectious Valerie Cruz FAVOURITES FOOD/S: BOOK/S: MOVIE/S: SONG/S: DO YOU PLAY A MUSICAL INSTRUMENT? FAVOURITE MUSICAL INSTRUMENT: ACTOR/ESS: COLOUR: CAR: FLOWER: GEM STONE: ANIMAL: TIME OF DAY: SEASON: DESTINATION: HISTORICAL FIGURE: PERSON YOU WOULD MOST LIKE TO MEET: WHY? FAVOURITE SCHOOL: ANY SPECIAL AWARDS/ACHIEVEMENTS: FAVOURITE QUOTE: PERSONAL PREFERENCES/ABILITIES ARE YOU SKILLED: HOW WOULD YOU RATE YOUR ABILITY IN MATH: LITERARY SKILLS: SCIENTIFIC/ RESEARCH ABILITIES: ARTICTIC TALENTS: MUSIC SKILLS / ABILITIES: ATHLETIC ABILITIES: HOW MANY LANGUAGES CAN YOU SPEAK? Cheese and Lasagne The Prophet A Knight s Tale and Star Wars Drunken Lullabies; Tash Sultana Piano Piano Ryan Reynolds Green Audi Frangipani Labradorite Dogs Afternoon Spring and Summer Anywhere on the beach or in a forest Nelson Mandela Tash Sultana Love her music English, Tourism and Consumer Studies Won a poetry award in primary school, which was also published in a book. But a smile never grins without tears to begin, for each kiss is a cry we all lost MECHANICALLY / TECHNICALLY 2: English and Afrikaans
3 SPECIAL SKILLS & PERSONALITY OF FAMILY MEMBERS Music / Artistic / Athletic / Scientific / Math skills / Personality / Employment / Hobbies / Other interesting facts MOTHER: My mother is amazing. She is smart, funny, generous, caring and loving. I can talk to her about anything, she is easy-going and creative. She is funny and genuine. FATHER: My father is very strict, he is also driven and ambitious. He loves with all he has and will never admit that he is actually a big softy SISTER: My sister is strong, intuitive, ambitious and smart. She has a temper although a softy at heart. ½ SISTER: She is in high school. I haven t seen her since she was a small child. She may be outdoorsy. DONORS HANDWRITING SAMPLE KEIRSEY TEMPERAMENT: GUARDIAN TO FOLLOW
4 FACIAL CHARACTERISTICS Face Shape: Square/Heart Eye Shape: Hooded / Slightly Down Turned / Almond / Round / Protruding Eye Set: Narrow / Close / Average / Deep/ Wide Eye Size: Small / Average / Large Eye colour: Brown Lip Shape: Full / Thin / Flat upper Lip / Perfect / Large top lip / Droopy shape Nose Shapes: Wavy / Snub / Flat / Aquiline / Upturned / Straight Hair Line: Straight / Round / Widow s Peak Hair form: Wavy / Soft Curls / Straight / Ethnic Hair Texture: Average / Thick / Fine / Coarse / Thin Premature Graying: Yes / No If yes, at what age: N/A Hair Colour: Medium Brown Present hair loss: None / Thinning Complexion: Medium Tan Ability: None / Slight / Medium / Easy Cheek Bones: High / Low / Wide / Flat / Pointed Facial Features: Moles / Few Freckles / Dimples / Beauty Spots / Cleft Chin / Gap tooth /Overbite/ None PHYSICAL CHARACTERISTICS Body Shape: Lean column Height: 1.63m Weight: 63.0kg BMI: 23.7 Build: Petite/Small/Medium/Athletic/Large/Stocky Hands: Right-handed/Left-handed/Ambidextrous
5 MEDICAL PROFILE PERSONAL HEALTH HISTORY Blood Group (ABO): N/A Rhesus: N/A Are you adopted? No Are either of your parents adopted? No Vision (without corrective lenses): Poor / Fair / Good / Excellent Do you wear corrective lenses? Yes If yes, for what problem(s)? Farsighted / Short-sighted / Other: Explain: N/A Hearing (without corrective aids): Poor / Fair / Good / Excellent Do you wear corrective aids? No If yes, for what problems? N/A Do you smoke cigarettes? Very occasionally If yes, how many per day? NA Do you drink alcohol? Yes If yes, how often? Weekends mostly Diet: Vegetarian / Non vegetarian / Other: N/A Allergies: No If yes, are they to: Food(s) / Medication(s) / Cosmetics / Environmental / Animals / Insects For each allergy, describe specific substance and reaction(s) and age first noticed: Substance: N/A Reaction(s): N/A Age: N/A Explain allergies you have outgrown: N/A Exercise/ Sporting activities: None / Occasional / Regular Type of Exercise: Underwater hockey and surfing Have you had any surgery (ies)? Yes If yes please explain: Tonsillectomy at age 5 Have you had any hospitalisation(s) not mentioned above? No Have you had a blood transfusion? No Are you a blood donor? Yes Have you ever been excluded from blood donation for reason of infectious disease? No Have you had major radiation or x-ray exposure? No If yes, explain: N/A Have you had any psychological or psychiatric care? No If yes, explain: N/A Are you currently taking any medications, prescribed or over the counter? No If yes, please list: N/A Are you currently using any recreational drugs? Seldom If yes, please list: Weed Do you have any physical deformities for which you have sought surgical corrections? No If so, please explain: N/A
6 Have you ever been tested as a carrier of? Tay-Sach s disease Sickle Cell disease Thalassemia Cystic Fibrosis Carrier Non-carrier Unknown FERTILITY HISTORY AMH: Not tested, as AFC was found to be adequate by a fertility specialist AFC: Measured Have you ever been pregnant? No Do you have any children? No If yes, please complete sex: N/A Any special comments concerning your children? N/A Are you currently on any form of birth control? No Do you have a regular period? Yes Is there any history of fertility problems in your family (difficulty conceiving or miscarriages)? No PSYCHOLOGICAL ASSESSMENT All our donors undergo psychological screening prior to their first donation. This assessment and subsequent assessments are valid for one year. SEUAL HEALTH HISTORY Have you or any of your sexual partner been in contact with anyone or have personally been treated for any of the following: NO TO ALL Self Partner When HIV NSU (non specific urethritis) Syphilis Gonorrhea Chlamydia Venereal Warts Herpes Viral Hepatitis B or C Hemophilia Received human-derived clotting factor concentrates IV (intravenous) drug use Other sexually transmitted diseases Do you practice safe sex at all times? No Do you consider your sexual practices risky for HIV infection? No Have you or any of your sexual partners: -engaged in sexual relations with a partner of the same sex during the last 5 years? Yes -had sex in exchange for money or drugs in the preceding 5 years? No -within the past 12 months undergone tattooing, acupuncture, ear or body piercing? February 2018
7 Year of Birth Health Status Age at time of Death Cause of Death Eye Colour Hair Colour Complexion Height (m) Weight (kg) Build FAMILY BIO/HISTORY Mother 1963 Good Hazel Black Olive 1.57 Medium Father 1974 Excellent Blue Blond Light Medium Brother Sister 1995 Excellent Brown Brown Light Medium ½ Sister 2004 Excellent Blue Blond Medium Large MGM 1944 Excellent Green Brown Blond Light Fine MGF 1940 Excellent Brown Black Olive 1.87 Medium PGM Deceased Unknown Blue Blond Light Medium PGF Deceased Unknown Brown Brown Light Medium (MGM = Maternal Grandmother, MGF = Maternal Grandfather, PGM = Paternal Grandmother, PGF = Paternal Grandfather, - = Unknown) How many blood siblings are in your immediate family (including yourself)? 2 Number of Males: 0 Number of Females: 2 How many half siblings are in your immediate family? 1 If so, from which parent? Father Number of Males: 0 Number of Females: 1 How many adopted siblings are in your immediate family (including yourself)? 0 Number of Males: 0 Number of Females: 0 Are there any twins or triplets in your family? Yes If yes, what relations are they to you? 2 nd cousins are triplets Are there any known genetic diseases or conditions that run in your family? No If yes, please identify: N/A Have you or any family members described above had genetic counseling? No If yes, please describe: N/A Are there any members of your family with a history of learning disabilities? No If yes, please explain: N/A
8 Medical problems which are present in biological family members: You Mother Father Sibling MGM MGF PGM PGF HEART Stroke Heart attack Heart disease or defect 1. from birth 2. other Hardening of the arteries High blood pressure Hereditary high cholesterol High cholesterol level BLOOD Anemia Sickle-cell anemia Hemophilia/bleeding disorder HIV / AIDS Leukemia Other blood disorder RESPIRATORY Asthma Lung cancer Emphysema Tuberculosis GASTRO-INTESTINAL Ulcer of stomach/duodenum Hepatitis (all types) Cirrhosis Other liver disease Ulcerative colitis Crohn's disease Pyloric stenosis Multiple Polyposis of colon Rectal disorder METABOLIC/ENDOCRINE Diabetes (age of onset) Thyroid disease Goiter Hyperactivity Phenyl Ketonuria (PKU) Cystic fibrosis Dwarfism Lupus/other auto immune diseases URINARY Kidney disease Other disease/defect of urinary tract Father had a stroke in He led an extremely unhealthy lifestyle and was a heavy smoker. Father and PGF were both diagnosed with high cholesterol in their 40 s. Mother had asthma briefly during her teens. She outgrew it before adulthood. Mother and MGM have high blood pressure which is well controlled with tablets.
9 You Mother Father Sibling MGM MGF PGM PGF NEUROLOGICAL Migraines Mental retardation Senility before age 50 Multiple Sclerosis Cerebral Palsy Epilepsy/seizure Hydrocephalus Spina bifida neural tube defect Tuberous Sclerosis Parkinsonism Creutzfeldt-Jakob Disease Scoliosis MENTAL HEALTH Depression Schizophrenia Manic depressive/bipolar disorder Alcoholism Drug abuse, misuse or addiction MUSCLE/BONE/JOINTS Muscular dystrophy Loss of muscle coordination Other chronic muscle disease Osteoporosis Marfan Syndrome Arthritis SIGHT/SOUND/SMELL Deafness before age 60 Deformity of the ear Cataracts before age 50 Blindness Colour blindness Severe Myopia Glaucoma Retinoblastoma Retinitis Pigmentosa Other sight/sound/smell disorder SKIN Acne Albinism Eczema Pigmentation disorders Neurofibromatosis Other disorders of the skin CANCER Breast Ovarian Colon Skin Thyroid cervical Uterine Other GENETIC / CHROMOSOME Down Syndrome Turner Syndrome Fragile Syndrome OTHER Mother s migraines started around age 17/18. She gets them a few times a year. Sister s acne started at age 21, and is related to the injectable contraceptive. Mother was diagnosed with stomach cancer in She had an operation to remove it. She did not have chemotherapy or radiation and has since adopted a healthy lifestyle.
EXPANDED PROFILE: Eve737
EPANDED PROFILE: Eve737 SOME INTERESTING FACTS ABOUT: YOUR STAR SIGN: WHAT DO YOU CONSIDER AS YOUR BEST FACIAL FEATURE: WHAT DO YOU CONSIDER TO BE YOUR BEST PHYSICAL FEATURE: HOW WOULD YOU DESCRIBE YOUR
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Patient Profile Patient Name: DOB: Address: City: State: Zip: Spouse/Significant Other: Children's names and ages: Patient Employer: Address:
Patient Profile Patient Name: DOB: Address: City: State: Zip: Phone# (H): (W): Other: Email: May Dr. Strong to leave medical information on your answering machine/voicemail? YES NO May Dr. Strong to send
PATIENT INFORMATION FORM (WOMEN ONLY)
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Denise L. Newman, Ph.D.
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HEALTH SCREENING QUESTIONNAIRE. Work-up. Donor ID EdgeCell #:
HEALTH SCREENING QUESTIONNAIRE Héma-Québec Registre des Donneurs de Cellules Souches 4045 Côte-vertu, St-Laurent, QC, Canada, H4R 2W7 Tél : + 514-832-1031 Fax : + 514-832-0266 www.hema-quebec.qc.ca CT
SCHNEIDER MEDICAL GROUP, PA History Intake Form (Please Print)
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TEXAS VASCULAR ASSOCIATES, P.A. PATIENT CLINICAL INTAKE FORM
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Your History: Please check the appropriate box for the conditions as they apply to you:
MEDICARE ANNUAL WELLNESS VISIT QUESTIONNAIRE Patient Name DOB Enrolled in Medicare of last Annual wellness exam Providers and Suppliers of Your Medical Care Please list all providers and suppliers of your
Cardiovascular Genetics Clinic Vascular Questionnaire
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Patient Medical Information. Last. Sex: M / F Age: Date of Birth: Home Address: City: State: Zip Code: Business Address: City: State: Zip Code:
Patient Medical Information Name: First Middle Last Sex: M / F Age: Date of Birth: Social Security # Driver s License # Home Address: City: State: Zip Code: Home Phone: Occupation: Cell: Employer: Business
REDROCK MEDICAL GROUP INITIAL HISTORY AND PHYSICAL
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JACQUELYNE GORTON, MSN, JD NURSE ATTORNEY
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Patient History Form
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Patient History Form
Patient Personal Information Name: Date: Age: Occupation: Employer's name: Briefly describe your daily activities at work: Sex: male female Marital Status: single married divorced widowed Spouse's name:
NC Neuropsychiatry, PA HEALTH QUESTIONNAIRE
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Name Age DOB Sex M F Your relationship status: Single Married Life partner Widowed Address
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Creve Coeur Family Medicine, LLC
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Patient Name Date of Birth MALE / FEMALE Date. Left handed or Right handed. Marital Status: Single Married Divorced Widowed Children?
PH NEW PATIENT HISTORY Patient Name Date of Birth MALE / FEMALE Date Occupation: Left handed or Right handed Marital Status: Single Married Divorced Widowed Children? Y or N # Previous Treating Physician:
PATIENT HEALTH QUESTIONNAIRE Radiation Oncology
REVIEWED DATE / INITIALS Safety: Are you at risk for falls? Do you have a Pacemaker? Females; Is there a possibility you may be pregnant? Allergies: If YES, please list medication allergies: Do you have
Southern Maine Integrative Health Center Adult Intake Form
Southern Maine Integrative Health Center Adult Intake Form Patient Name: Address: Birthdate: / / Age: / / City: State/Zip: Home Telephone: ( ) Work Telephone: ( ) Employer: Cell phone: ( ) Email Address:
Single Married Divorced Widowed Male Female
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