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Donor 5410: Enhanced Donor Profile

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Pricing & Ordering Information

Purchase Bundle Options

Purchase Qty Options
1-3 Unit Purchase
  • Regular Storage Options Apply: $50 per month, $190 for 6 months, $360 for one year
  • No Buyback Option
4 Unit Purchase
  • 6 months of free storage
  • 6 month buy back at 50% of the original purchase cost, when stored at Xytex
6 Unit Purchase
  • 1 year of free storage
  • 1 year buy back at 50% of the original purchase cost, when stored at Xytex
  • Complimentary Highest Motility
8 Unit Purchase or more
  • 2 years of free storage
  • 2 year buy back at 50% of the original purchase cost, when stored at Xytex
  • Complimentary Highest Motility

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Unit Type Available for Donor #5410 Price Per Unit
Washed ID Disclosure $835
Unwashed ID Disclosure $700
ART ID Disclosure Units $550

Due to inventory, above prices do not guarantee that listed vial types are currently available.
Please contact our customer service team to verify if the needed vial type is in stock.


Canadian Customers

Please contact your Canadian distributor for this donor's availability.

Outreach Health Services - 1-866-785-4709
CAN-AM Cryoservices - 1-888-245-3471
ReproMed - 1-877-317-6079 ext 2

General Information
Donor ID:
5410
Year of Birth:
1987
Marital Status:
Single
Number of Children:
 
Religion:
None
Occupation:
Chiropractor
Blood Type:
A +
Ethnicity:
Maternal: Irish, Paternal: German
Race:
Caucasian
CMV Status:
POS
Last Medical History Update:
Dec 16, 2016
Reported Pregnancy:
Yes
Canadian Compliance:
Yes
UK Compliance:
No
Identity Disclosure:
Yes

Donor Photos

6 photos available
Child Photo
Adult Photo
Audio File:
Not Available

Genetic Testing Performed:

Genetic Testing Performed-Please review the list of genetic tests performed before choosing a donor because donors have different levels of testing. Genetics is very complicated and testing can only reduce but not eliminate the risk of a donor being a carrier of a particular condition.

Get to Know Your Donor
I liked to be called Alex. I was raised by both my parents in a very stable and loving household. While they provided the necessary elements to grow, they also taught me to be extremely independent and create my own destiny. They were the first to be by my side during my accomplishments, but I never asked for help and I think that led me on the path to be the person I am today. Though I never put too much faith into astrology, I am a water sign and exhibit many of the qualities that come with a Pisces nature. I’m extremely compassionate, easy going, empathetic, optimistic, sensitive, and overall fairly selfless. I have an extremely charismatic personality and I believe in never meeting a stranger. As an extrovert, I enjoy nothing more than walking into an unfamiliar social gathering and seeing how many new friends I can make through my charm and intuition. I give everything I can to my friends/family and will go completely out of my way to help someone in need. I have found that people are naturally attracted to my kinetic energy and friendly demeanor, so I am very wealthy in relationships and love everyone in my life dearly. When it comes to dating, I believe in unfettered romanticism and use my creativity and sensitive nature to go beyond what’s considered normal.

Besides my overall personality, I’m a hard-worker and am constantly setting new standards or goals for myself. I want to achieve my maximum potential and I look forward to the challenges I’ll face in life because they will teach me wisdom for the future. In my free time, I enjoy being athletic and participating in anything social. I’m a morning person so I love being extremely active in the early part of the day. I enjoy running, hiking, water sports, and intramurals at the park. I actively attend any festival or social gathering that comes my way and love to travel around the world to see what adventures await. I am thankful for extremely intelligent parents who blessed me with a brain that allows me to possess a phenomenal memory, pick up things fairly quickly, and retain information very well. I love a good challenge and will use anything in my repertoire to try and overcome whatever stands in my way.

If there’s only one thing you take away from reading this personal essay, let it be this: I fully believe I am a good person and my attitude towards life and the people that surround me has led me to be so incredibly happy. I don’t regret anything in my past and live by the philosophy that every day is a new beginning.

Sincerely,
Donor 5410

Physical Attributes
Height:
6'00" (182.88 cm)
Weight:
175 lbs (79 kg)
Eye Color:
Green
Hair Color:
Brown, Medium
Hair Texture:
Coarse
Hair Loss:
None
Hair Type:
Average
Dominant Hand:
Right
Hairy Chest:
Yes
Hairy:
No
Ear Lobes:
Attached
Beard Color:
Brown, Medium
Eyebrows:
Medium
Dimples:
No
Acne:
No
Acne Information:
 
Shoe Size:
11 (D)
Body Build:
Medium
Freckles:
None
Skin Tone:
Brown, Light
Face Shape:
Square
Lips:
Normal
Nose Shape:
Normal
Long Eyelashes:
No

Purchase Options
xySingle
Purchase this Enhanced
PROFILE for Only:
$65

xyStandard
Purchase Standard Unlimited
ACCESS for Only:
$165

Includes Access to All Enhanced Donor Profiles, and Child and Adult Photos
xyUltra
Purchase ULTRA Unlimited
ACCESS for Only:
$195

Includes Access to All Enhanced Donor Profiles, Donor Photos and Audio Files
*Audio files are only available for specific donors.
Genetic Testing

Over the years, Xytex has expanded genetic testing of donors as genetic knowledge and technology have advanced. As a result, not all donors have been tested for the same conditions or with the same methods. "xyGene" donors have undergone the most extensive testing. For more information about genetic testing view our "Genetics Video and FAQs."

This donor has been evaluated for carrier status of the listed conditions. A negative result reduces, but does not eliminate, the likelihood of the donor being a carrier. If you are a known carrier of a genetic condition please contact us, and we will provide a copy of the donor's test reports to your physician and/or genetic counselor.

 

Normal complete blood count and hemoglobin analysis; does not exclude silent carrier status or alpha thalassemia minor
Normal complete blood count and hemoglobin analysis
No disease-causing mutations detected
No disease-causing mutations detected
Normal male karyotype
No disease-causing mutations detected
No disease-causing mutations detected
No disease-causing mutations detected
No disease-causing mutations detected
No disease-causing mutations detected
No disease-causing mutations detected
No disease-causing mutations detected
No disease-causing mutations detected
No disease-causing mutations detected
No disease-causing mutations detected
No disease-causing mutations detected
No disease-causing mutations detected
No disease-causing mutations detected
No disease-causing mutations detected
Normal complete blood count and hemoglobin analysis
No disease-causing mutations detected (2 copies)
No disease-causing mutations detected
No disease-causing mutations detected
No disease-causing mutations detected
No disease-causing mutations detected
Donor Health Information
Medication Allergy:
No
Food Allergy:
No
Pet Allergy:
No
Hay Fever Allergy:
No
Insect Allergy:
No
Vaccine Allergy:
No
Healthy Teeth:
Yes
Braces:
Yes
Back Problems:
No
Bronchitis:
Yes
Chicken Pox:
Yes
Chicken Pox Age:
0
Vertigo:
No
Eyesight Correction:
Yes
Near or Far Sighted:
Nearsighted
Skin Infection:
No
Gallstones:
No
Removed Gall Bladder:
No
Hernia:
No
Mumps:
No
Measles:
No
Measles Age:
 
German Measles:
No
German Measles Age:
 
Sinus Infection:
No
Stomach Ulcers:
No

*The medical and social history was provided by the donor and cannot be verified for accuracy.

Personality and Interests Attributes
Athletic
1
2
3
4
5

Couch Potato

Optimistic
1
2
3
4
5

Pessimistic

Assertive
1
2
3
4
5

Passive

Leader
1
2
3
4
5

Follower

Easy Going
1
2
3
4
5

Controlling, Rigid

Artistic
1
2
3
4
5

Michael Angelo Who?

Extrovert
1
2
3
4
5

Introvert

Celebrity Look Alike:
Tobey Maguire
Awards:
Dean’s List, scholar award

Favorite Hero:
Terry Fox-lost leg to cancer-raised money for cancer awareness by running across Cansda and starting the “Marathon of Hope”.
Vegetarian:
No

Accomplishments:
Getting my doctorate, starting a private practice
Adjectives:
Optimistic, Energetic, Charismatic

Perfect Day:
Running along the beach in the morning, reading, and sunbathing to the sound of the waves beating all day.
Character Flaws:
Defensiveness, overly eager to please

Favorite Author:
Robert Jordan
Favorite Book:
 

Favorite Author/Book Explanation:
I appreciate the worlds he creates with his wild imagination.
Fine Art Skills:
Painting
Technical/Mechanical Ability:
Personality:
Adventurous and full of charisma. Always in a good mood and can find the light in every situation.
Favorite Music:
Indie Rock
Favorite Music Explanation:
Eclectic and not overplayed.
Skills Hobbies and Interest:
Hiking, Research, Sports, Technology, Video Games
Education Information

In School: No
In School Major: Unknown
Post Graduate: This donor holds a post graduate degree.

Training Type:

College Degrees:
Bachelor of Science, Doctor of Chiropractic

Birth Information
Carried to Term:
Yes
Pregnancy Complications:
No
Birth Weight:
9 lbs
Birth Length:
21 inches
Twin:
No
Twin Type:
 

Childhood Health:
Excellent

Immediate Family Medical History
Family Member:
Brother
Hair Color:
Blonde, Dark
Eyesight:
 
 
 
Freckles:
None
Hair Texture:
Coarse
 
 
Health Status:
Good
Skin Tone:
Medium
Dominant Hand:
 
Year of Birth:
1985
Cause of Death:
 
Hair Loss
 
Height:
5' 11'' (180.34 cm)
Age at Death:
 
Body Hair:
Straight
Weight:
180 lbs. (81 kg)
Occupation:
Teacher
Eye Color:
Green
Half Siblings:
No
Education:
College
Body Build:
Medium
Half Siblings
Parent:
 
Eyesight
Correction:
 
Near or
Far Sighted:
 
Comments:
Has 3 kids, ages 1 month-3 yrs., all healthy. He’s competitive. Enjoys woodworking, technology, and engineering.
Family Member:
Father
Hair Color:
Brown, Medium
Eyesight:
 
 
 
Freckles:
None
Hair Texture:
Fine
 
 
Health Status:
Good
Skin Tone:
Medium
Dominant Hand:
 
Year of Birth:
1958
Cause of Death:
 
Hair Loss
 
Height:
6' 00'' (182.88 cm)
Age at Death:
 
Body Hair:
Straight
Weight:
190 lbs. (86 kg)
Occupation:
Computer Network Analyst
Eye Color:
Blue/Green
Half Siblings:
No
Education:
College
Body Build:
Large
Half Siblings
Parent:
 
Eyesight
Correction:
 
Near or
Far Sighted:
 
Comments:
He’s fun loving and has a good heart. Enjoys engineering, technology, and carpentry.
Family Member:
Mother
Hair Color:
Brown, Dark
Eyesight:
 
 
 
Freckles:
Few
Hair Texture:
Fine
 
 
Health Status:
Good
Skin Tone:
Medium
Dominant Hand:
 
Year of Birth:
1961
Cause of Death:
 
Hair Loss
 
Height:
5' 02'' (157.48 cm)
Age at Death:
 
Body Hair:
Wavy
Weight:
180 lbs. (81 kg)
Occupation:
VP of Conversion Department
Eye Color:
Brown, Dark
Half Siblings:
No
Education:
College
Body Build:
Medium
Half Siblings
Parent:
 
Eyesight
Correction:
 
Near or
Far Sighted:
 
Comments:
Has a round face. She’s very easy going and passive. Enjoys cooking and sewing.
Health Condition:
Diabetes (Non-Insulin Dependent) at age 52
Family Member:
Sister
Hair Color:
Brown, Medium
Eyesight:
 
 
 
Freckles:
None
Hair Texture:
Fine
 
 
Health Status:
Good
Skin Tone:
Medium
Dominant Hand:
 
Year of Birth:
1993
Cause of Death:
 
Hair Loss
 
Height:
5' 02'' (157.48 cm)
Age at Death:
 
Body Hair:
Straight
Weight:
110 lbs. (49 kg)
Occupation:
Student
Eye Color:
Green
Half Siblings:
No
Education:
College
Body Build:
Small
Half Siblings
Parent:
 
Eyesight
Correction:
 
Near or
Far Sighted:
 
Comments:
Has a heart shaped face. She is witty and good natured. Enjoys reading.
Paternal Family Medical History
Family Member:
Aunt
Hair Color:
 
Eyesight:
 
 
 
Freckles:
 
Hair Texture:
 
 
 
Health Status:
Good
Skin Tone:
 
Dominant Hand:
 
Year of Birth:
1954
Cause of Death:
 
Hair Loss
 
Height:
Age at Death:
 
Body Hair:
 
Weight:
Occupation:
 
Eye Color:
 
Half Siblings:
No
Education:
 
Body Build:
 
Half Siblings
Parent:
 
Eyesight
Correction:
 
Near or
Far Sighted:
 
Comments:
 
Family Member:
Aunt
Hair Color:
 
Eyesight:
 
 
 
Freckles:
 
Hair Texture:
 
 
 
Health Status:
Good
Skin Tone:
 
Dominant Hand:
 
Year of Birth:
1963
Cause of Death:
 
Hair Loss
 
Height:
Age at Death:
 
Body Hair:
 
Weight:
Occupation:
 
Eye Color:
 
Half Siblings:
No
Education:
 
Body Build:
 
Half Siblings
Parent:
 
Eyesight
Correction:
 
Near or
Far Sighted:
 
Comments:
 
Family Member:
Grandfather
Hair Color:
Brown, Medium
Eyesight:
 
 
 
Freckles:
Few
Hair Texture:
Thick
 
 
Health Status:
Deceased
Skin Tone:
Medium
Dominant Hand:
 
Year of Birth:
1924
Cause of Death:
Car Accident
Hair Loss
 
Height:
6' 00'' (182.88 cm)
Age at Death:
70
Body Hair:
Straight
Weight:
200 lbs. (90 kg)
Occupation:
Army Officer
Eye Color:
Blue
Half Siblings:
No
Education:
High School
Body Build:
Large
Half Siblings
Parent:
 
Eyesight
Correction:
 
Near or
Far Sighted:
 
Comments:
Had dimples. He was a hard worker. Enjoyed stamp collecting and piano.
Family Member:
Grandmother
Hair Color:
Blonde, Medium
Eyesight:
 
 
 
Freckles:
None
Hair Texture:
Thick
 
 
Health Status:
Deceased
Skin Tone:
Fair
Dominant Hand:
 
Year of Birth:
1929
Cause of Death:
Stroke
Hair Loss
 
Height:
5' 00'' (152.40 cm)
Age at Death:
72
Body Hair:
Wavy
Weight:
130 lbs. (59 kg)
Occupation:
Department Store Salesperson
Eye Color:
Blue
Half Siblings:
No
Education:
High School
Body Build:
Small
Half Siblings
Parent:
 
Eyesight
Correction:
 
Near or
Far Sighted:
 
Comments:
Had high cheekbones. She was the most supportive person I’ll ever know. Enjoyed cooking.
Health Condition:
Other Disease/Condition at age 70

Dementia
Health Condition:
Stroke at age 72
Family Member:
Uncle
Hair Color:
 
Eyesight:
 
 
 
Freckles:
 
Hair Texture:
 
 
 
Health Status:
Good
Skin Tone:
 
Dominant Hand:
 
Year of Birth:
1950
Cause of Death:
 
Hair Loss
 
Height:
Age at Death:
 
Body Hair:
 
Weight:
Occupation:
 
Eye Color:
 
Half Siblings:
No
Education:
 
Body Build:
 
Half Siblings
Parent:
 
Eyesight
Correction:
 
Near or
Far Sighted:
 
Comments:
 
Family Member:
Uncle
Hair Color:
 
Eyesight:
 
 
 
Freckles:
 
Hair Texture:
 
 
 
Health Status:
Good
Skin Tone:
 
Dominant Hand:
 
Year of Birth:
1952
Cause of Death:
 
Hair Loss
 
Height:
Age at Death:
 
Body Hair:
 
Weight:
Occupation:
 
Eye Color:
 
Half Siblings:
No
Education:
 
Body Build:
 
Half Siblings
Parent:
 
Eyesight
Correction:
 
Near or
Far Sighted:
 
Comments:
 
Family Member:
Uncle
Hair Color:
 
Eyesight:
 
 
 
Freckles:
 
Hair Texture:
 
 
 
Health Status:
Good
Skin Tone:
 
Dominant Hand:
 
Year of Birth:
1960
Cause of Death:
 
Hair Loss
 
Height:
Age at Death:
 
Body Hair:
 
Weight:
Occupation:
 
Eye Color:
 
Half Siblings:
No
Education:
 
Body Build:
 
Half Siblings
Parent:
 
Eyesight
Correction:
 
Near or
Far Sighted:
 
Comments:
He has a twin brother.
Family Member:
Uncle
Hair Color:
 
Eyesight:
 
 
 
Freckles:
 
Hair Texture:
 
 
 
Health Status:
Fair
Skin Tone:
 
Dominant Hand:
 
Year of Birth:
1960
Cause of Death:
 
Hair Loss
 
Height:
Age at Death:
 
Body Hair:
 
Weight:
Occupation:
 
Eye Color:
 
Half Siblings:
No
Education:
 
Body Build:
 
Half Siblings
Parent:
 
Eyesight
Correction:
 
Near or
Far Sighted:
 
Comments:
He has a twin brother.
Maternal Family Medical History
Family Member:
Aunt
Hair Color:
 
Eyesight:
 
 
 
Freckles:
 
Hair Texture:
 
 
 
Health Status:
Good
Skin Tone:
 
Dominant Hand:
 
Year of Birth:
1951
Cause of Death:
 
Hair Loss
 
Height:
Age at Death:
 
Body Hair:
 
Weight:
Occupation:
 
Eye Color:
 
Half Siblings:
No
Education:
 
Body Build:
 
Half Siblings
Parent:
 
Eyesight
Correction:
 
Near or
Far Sighted:
 
Comments:
 
Family Member:
Aunt
Hair Color:
 
Eyesight:
 
 
 
Freckles:
 
Hair Texture:
 
 
 
Health Status:
Deceased
Skin Tone:
 
Dominant Hand:
 
Year of Birth:
1953
Cause of Death:
Lung Cancer (Smoker)
Hair Loss
 
Height:
Age at Death:
 
Body Hair:
 
Weight:
Occupation:
 
Eye Color:
 
Half Siblings:
No
Education:
 
Body Build:
 
Half Siblings
Parent:
 
Eyesight
Correction:
 
Near or
Far Sighted:
 
Comments:
 
Health Condition:
Cancer (Lung) at age 55

Smoker
Family Member:
Grandfather
Hair Color:
Brown, Dark
Eyesight:
 
 
 
Freckles:
Few
Hair Texture:
Coarse
 
 
Health Status:
Deceased
Skin Tone:
Brown, Light
Dominant Hand:
 
Year of Birth:
1937
Cause of Death:
Died in Sleep
Hair Loss
 
Height:
5' 10'' (177.80 cm)
Age at Death:
70
Body Hair:
Straight
Weight:
210 lbs. (95 kg)
Occupation:
Army Officer
Eye Color:
Brown, Dark
Half Siblings:
No
Education:
High School
Body Build:
Large
Half Siblings
Parent:
 
Eyesight
Correction:
 
Near or
Far Sighted:
 
Comments:
He was serious and stoic. Enjoyed carpentry.
Family Member:
Grandmother
Hair Color:
Brown, Dark
Eyesight:
 
 
 
Freckles:
None
Hair Texture:
Fine
 
 
Health Status:
Deceased
Skin Tone:
Brown, Light
Dominant Hand:
 
Year of Birth:
1924
Cause of Death:
Died in Sleep
Hair Loss
 
Height:
5' 02'' (157.48 cm)
Age at Death:
75
Body Hair:
Wavy
Weight:
180 lbs. (81 kg)
Occupation:
Homemaker
Eye Color:
Brown, Dark
Half Siblings:
No
Education:
High School
Body Build:
Medium
Half Siblings
Parent:
 
Eyesight
Correction:
 
Near or
Far Sighted:
 
Comments:
Had dimples. She was highly intelligent. Enjoyed sewing.
The following medical conditions apply to the donor and his BLOOD RELATIVES ONLY
(grandparents, parents, aunts, uncles, cousins, brothers, sisters, nieces, nephews, and children of the donor). Please click on the Medical History Questionnaire to see all the questions that the donor must answer. If the donor answers "yes" to any high risk question, the donor is ineligible.
Medical History Questionnaire
Autoimmune Diseases   Yes No Which
Relative
Father's
Side
Mother's
Side
Age of
Onset
CREST Syndrome     X        
Lupus     X        
Scleroderma     X        
Sjorgen's Syndrome     X        
Blood Diseases   Yes No Which
Relative
Father's
Side
Mother's
Side
Age of
Onset
Anemia     X        
Fanconi Anemia     X        
Hemophilia     X        
Immunodeficiency     X        
Leukemia     X        
Sickle Cell     X        
Thalassemia     X        
VonWillebrand's disease     X        
Cancer   Yes No Which
Relative
Father's
Side
Mother's
Side
Age of
Onset
Cancer (Breast)     X        
Cancer (Lung)   X   Aunt   X 55
Cancer (Other)     X        
Cancer (Skin)     X        
Lymphoma     X        
Melanoma     X        
Tumor     X        
Cardio Vascular Diseases   Yes No Which
Relative
Father's
Side
Mother's
Side
Age of
Onset
Congenital Heart Disease     X        
Heart Attack     X        
Heart Disease     X        
High Blood Pressure     X        
High Cholesterol / Triglycerides     X        
Stroke   X   Grandmother X   72
Congenital Malformations   Yes No Which
Relative
Father's
Side
Mother's
Side
Age of
Onset
Deviated Septum     X        
Malformations (Cleft Lip)     X        
Malformations (Cleft Palate)     X        
Malformations (Club Foot)     X        
Malformations (Hypospadias)     X        
Malformations (Other)     X        
Malformations (Polydactyly)     X        
Undescended Testicles     X        
Gastro-Intestinal Diseases   Yes No Which
Relative
Father's
Side
Mother's
Side
Age of
Onset
Gallstones     X        
GI (Crohns)     X        
GI (Diverticulitis)     X        
GI (Other)     X        
GI (Pyloric Stenosis)     X        
GI (Ulcerative Colitis)     X        
GI (Ulcers)     X        
Hemochromatosis     X        
Hepatitis     X        
Kidney Disease   Yes No Which
Relative
Father's
Side
Mother's
Side
Age of
Onset
Adrenal Hyperplasia     X        
Born with 1 kidney     X        
Kidney (Other)     X        
Kidney disease of urinary tract disorder     X        
Kidney Disorder     X        
Polycystic Kidney Disease     X        
Progressive Kidney Disease     X        
Mental Health   Yes No Which
Relative
Father's
Side
Mother's
Side
Age of
Onset
Mental (Depression)     X        
Mental (Manic Depressive)     X        
Mental (Schizophrenia)     X        
Mental Retardation     X        
Obsessive-compulsive disorder     X        
Metabolic / Endrocrine Dis.   Yes No Which
Relative
Father's
Side
Mother's
Side
Age of
Onset
Diabetes (Insulin Dependent)     X        
Diabetes (Non-Insulin Dependent)   X   Mother   X 52
Galactosemia     X        
Gaucher's disease     X        
Goiter     X        
Hypoglycemia     X        
Maple Syrup disease     X        
PKU or Inherited Metabolic Disorder     X        
Tay Sachs     X        
Thyroid Disorder     X        
Muscular / Bones / Joint Disease   Yes No Which
Relative
Father's
Side
Mother's
Side
Age of
Onset
Acondroplasia (Dwarfism)     X        
Arthritis (Other)     X        
Congenital Hip Disease     X        
Gout     X        
Loss of Muscle Coordination     X        
Marfan's Disease     X        
Muscular Dystrophy     X        
Osteoarthritis     X        
Osteoporosis     X        
Rheumatoid Arthritis     X        
Scoliosis     X        
Spinal Muscular Atrophy     X        
Neurological Diseases   Yes No Which
Relative
Father's
Side
Mother's
Side
Age of
Onset
ADD or ADHD     X        
Autism / Aspergers     X        
Canavan's disease     X        
Cerebral Palsy     X        
Disorders of the spinal cord     X        
Dyslexia     X        
Familial dysautonomia     X        
Lesch-Nyhan Syndrome     X        
Migraines     X        
Mucolipidosis type IV     X        
Neurologic (Alzheimer's)     X        
Neurologic (Creutzfeld-Jacob Disease)     X        
Neurologic (Epilepsy)     X        
Neurologic (Guillain Barre)     X        
Neurologic (Huntington's)     X        
Neurologic (JC Virus)     X        
Neurologic (Lou Gehrig's Disease)     X        
Neurologic (Multiple Sclerosis)     X        
Neurologic (Neural Tube Defect)     X        
Neurologic (Neurofibrimatosis)     X        
Neurologic (Parkinson's Disease)     X        
Neurologic (Subacute Sclerosing Panencephalitis)     X        
Nieman-Pick     X        
Spongioform encephalopathy / prion disease     X        
Tourette Syndrome     X        
Respiratory Disease   Yes No Which
Relative
Father's
Side
Mother's
Side
Age of
Onset
Allergies (Drug)     X        
Allergies (Food)     X        
Allergies (Hay Fever)     X        
Allergies (Insect)     X        
Allergies (Other)     X        
Allergies (Pet)     X        
Asthma     X        
Emphysema     X        
SARS     X        
Tuberculosis     X        
Sight / Sound / Smell   Yes No Which
Relative
Father's
Side
Mother's
Side
Age of
Onset
Cataracts     X        
Deafness     X        
Deafness (before age 50)     X        
Ear deformity     X        
Eyesight (Blindness)     X        
Eyesight (Color Blindness)     X        
Eyesight (Glaucoma)     X        
Eyesight (Other)     X        
Eyesight (Retinoblastoma)     X        
Macular degeneration     X        
Skin   Yes No Which
Relative
Father's
Side
Mother's
Side
Age of
Onset
Albinism     X        
Eczema     X        
Pigmentation disorders (including Vitiligo)     X        
Psoriasis     X        
Skin Disease     X        
Additional Information