Name Year of birth Marriage Staus: Married Single Widowed Divorced Separated Height Weight at age 25 Hair Color at age 25 Hair Type: Straight Wavy Curly Kinky Present Hair loss: None Thinning Moderate Balding Extensive Balding   Eye Color Skin Color Race Occupation: Education:   Give the country of origin of most of your ancestors and yourself: (i.e.,Germany, Ireland, etc.) List any special interests or hobbies:   Which best describes you at age 20? Athletic Active Average Inactive Which best describes your musical ability? Sing or play instrument proficiently Evidence of good ability but untrained Ability unknown but enjoy listening Tone deaf Do you have skills in any of the other fine arts? How would you rate your manual dexterity? Excellent Good Average Poor How often do you lose your temper? Frequently Seldom Never Allowing for your age, how would you rate your physical stamina? Above Average Average Below Average Have you ever excelled in any physical activity: Which best describes you? Extrovert Slight Extrovert Average Slight Introvert Introvert If you have ever taken an intelligence test: state which test if known: your score: and your age at the time: Are you tactful and work well with your associates? Above Average Average Below Average How many children do you have? Please give brief description of their health, intelligence, and abilities. Describe any significant intellectual, artistic, or academic achievement of your parents or siblings

1. Have you ever had any of the following: Yes No Hay fever Asthma Drug allergies (Specify) Food allergies (Specify) Insect allergies Skin Photosensitivity Eczema Psoriasis (scaly elbows) Birthmark Vitiligo (areas of depigmentation) Other chronic skin disease (Specify) Serious dental malocclusion Cataract Strabismus (crossed eyes; one eye turned out) Glaucoma Color blindness Night blindness Eyesight deficiency not correctable with glasses Blindness (Specify cause or diagnosis) Deafness Other hearing loss (Specify cause or diagnosis) Congenital hip dislocation Club foot (talipes equinovarus) Cleft lip and/or palate Dwarfism Arthritis Abnormalities of bone growth and development Other chronic skeletal system disease Muscular dystrophy Myotonia Abnormal postural positions Malignant hyperthermia Myasthenia gravis Huntington's chorea Parkinson's disease Epilepsy Multiple sclerosis Have you ever suffered paralysis of a limb for an extended period of time? Familial spastic paralysis Ataxia Tremor Sensory disturbance (for example, increased pain perception, unprovoked tingling, etc.) Muscle wasting Tic Stuttering or stammering or other speech impediment Sickle Cell Anemia or trait Cooley's Anemia or thalassemia Other anemia (for example pernicious, spherocytosis, etc.) Other hemoglobinopathy Hemophilia Lupus (Systemic Lupus Erythematosis) Cystic Fibrosis Gaucher's disease or other lipid storage disease PKU (phenylkatonuria) Alcaptonuria Any other inherited metabolic disorder (Specify) Marfan's syndrome Ehlers-Danlos syndrome Neurofibromatosis Any coffee-colored spots of skin about the size of a nickel or lumps under the skin. If so, how many? Chromosomal translocation Other chromosomal abnormality Brain defect or damage Homosexual tendency Exposure to mutagenic agents (for example radiation, chemotherapy, other) Leukemia Lymphoma Other cancer Congenital heart disease or defect Atherosclerosis Blood lipid abnormality (cholesterol, triglyceride, etc.) Insulin-dependent diabetes Insulin-nondependent diabetes Progressive kidney disease Polycystic kidneys Born with solitary kidney Gout, kidney stones, or hyperuricemia Pyloric stenosis Colon polyps (polyps of gastrointestinal tract) Congenital malformation of gastrointestinal tract Chronic malabsorption syndrome Ulcerative colitis Crohn's disease (regional enteritis) Porphyria Amyioidosis Wilson's disease Migraine headaches Other severe or disabling headaches Learning disability Retinoblastoma Dupuytren's Contracture Ankylosing spondylitis Depression Nervous breakdown or extreme nervousness Spells of unprovoked anxiety Hysteria Inability to function due to emotional upset Phobias Suicidal tendency or attempts Hot or violent temper Hallucinations Failing memory Great swings of mood from extreme euphoria to deep depression Delusions of greatness or omnipotence

2. Give details of any psychosis or other mental disorder you have suffered. Specifically, state if you ever received a diagnosis of Schizophrenia, Manic-depression, or Chronic recurrent depression   Have you ever received any psychiatric treatment for other than above? Yes No If yes, give detail   3. Are you at risk for any other physical or psychological condition, or disease that is thought to "run in your farnily"? Yes No If yes, please elaborate

(Parents, Grandparents, Sibling, or Child) 1. Mark "yes" if any one of your relatives has had the following conditions. For every "yes" answer, state which family member was/is affected, and the age of onset, as well as the exact diagnosis. (Use space at bottom of next page for additional information.) Yes No Hay fever Asthma Eczema Drug allergy (Specify) Food allergy (Specify) Skin photosensitivity Psoriasis Birthmark Vitiligo (areas of depigmentation) Other chronic skin disease (Specify) Serious dental malocclusion Cataract Strabismus Glaucoma Color blindness Night blindness Eyesight deficiency not correctable with glasses Blindness (Specify cause or diagnosis) Deafness or hearing loss (Specify cause or diagnosis) Congenital hip dislocation Club foot (talipes equinovarus) Cleft lip and/or palate Arthritis Ankylosing spondylitis Abnormalities of bone growth and development Chronic skeletal system disease Muscular dystrophy Myotonia Abnormal postural positions Loss of muscle coordination Malignant hyperthermia Myasthenia gravis Retinoblastoma Dupuytren's Contracture Thyroid disorders Huntington's chorea Parkinson's disease Chromosomal translocation Down's syndrome (mongolism) Other chromosomal abnormality Any form of mental retardation, intellectual dullness Brain defect or damage Cretinism (Congenital hypothyroidism) Neural tube (defects, spina bifida, meningocele, etc.) Klinefelter's syndrome Testicular feminization syndrome Transvestism Sex change operation Homosexuality or Lesbianism Hydrocephaly Anencephaly High levels of exposure to mutagenic agents (for example radiation, chemotherapy, other) Breast cancer Leukemia Lymphoma Other cancer Congenital heart disease or defect Cardiovascular disease High blood pressure Atherosclerosis Stroke Blood lipid abnormality (cholesterol, triglyceride, etc.) Seizure disorders Multiple sclerosis Paralysis of a limb for an extended period of time Familial spastic paralysis Ataxia Tremor Muscle wasting Tic (habit spasm) Stuttering or other speech impediment Sickle cell anemia/trait Thalassemia Other anemia Other hemoglobinopathy Hemophilia Nieman-Pick disease Histiocytosis Tay-Sachs disease Failing memory Drinking problem Psychiatric treatment Hallucinations Early senility or diagnosis of Alzheimer's disease Delusions of grandeur Lupus (Systemic Lupus Erythematosis) Cystic Fibrosis Gaucher's disease or other lipid storage Mucopolysaccharidoses PKU (phenylketonuria) Alcaptonuria Homocystinuria Any other inherited metabolic disorder Marfan's syndrome Ehlers-Danlos Syndrome Neurofibromatosis Anyone have coffee colored spots of the skin about the size of a nickel; and if so, how many? Or lumps under the skin. Insulin-dependent diabetes Insulin-nondependent diabetes

2. Have any of your relatives been diagnosed as having any psychosis or other mental disorder? Specifically, has a diagnosis of Schizophrenia, Manic-Depression, or Depression ever been made? Yes No Relative Affected Diagnosis Ever Hospitalized Chronic Disorder Yes No Age of Onset   3. Is there a history of early deaths in your family (for example, heart attack)? Yes No   If yes, give details   4. Has any female relative had more than two unexplained miscarriages? Yes No 5. Has any member of your family had one or more children with serious birth defects? Yes No Relation to you Number of Children Nature of defect(s) 6. Has any member of your family had any children who died in infancy or childhood? Yes No Who? How many children? Causes of death if known (other than accidental death) Age and health data on all blood relatives. Be specific and as accurate as possible. If you are not sure, put a question mark. Include stillborns and infant deaths. Relation to you Age if living If deceased Age at death Cause of death a. maternal grandmother: b. maternal grandfather: c. paternal grandmother: d. paternal grandfather: e. mother f. father g. brothers h. sisters i. children j. mother's sisters/brother k. father's sisters/brothers

Have you ever been found to be a carrier of: Tay-Sachs disease (if Jewish) Yes No Sickle cell disease (if black) Yes No B-Thalassemia Yes No G6PD Deficiency Yes No   Specify any occupation-related illness/disability   List all drugs, prescription and nonprescription, that you have taken dur-ing the past 12 months.   Did you wear contact lenses or glasses before age 45? Yes - No -If yes, please give present prescription:   Have you ever used any mind altering drugs such as marijuana, LSD, heroin or neuroleptic agents (tranquilizers, valium, thorazine, etc.) or chemo-therapeutic agents? If yes, give details. Yes No   List any serious trauma to yourself. Nature of trauma Post traumatic disorder: seizures learning disability memory lapse paralysis other List all medical hospitalizations: Date Problem List all operation: Date Operation   Did you have any complications ensuing from the surgery (bleeding, embolism, coma) from the anesthetic? Yes No Within the past 5 years have you had an abnormal electrocardiogram, x-ray, or other diagnostic test? Yes No Been advised to have any diagnostic test, hospitalization or surgery which was not completed? Yes No Have you ever had military service deferment, rejection or discharge because of a physical or mental condition? Yes No

Childhood Diseases HAVE YOU EVER HAD: Yes No Chicken Pox Chorea (St. Vitus Dance) Diphthena Measles - Regular Measles-German (Rubella) Mumps Whooping Cough Poliomyelitis (Polio) Rheumatic Fever Scarlet Fever Streptococcal Infection (Strep) HAVE YOU EVER HAD ANY OF THE FOLLOWING DISEASES OR DISORDERS: Yes No Amebic Dysentery Bronchiectasis (Coughing & Spitting) Bronchitis (chronic or acute cough) Bursitis Cirrhosis of Liver Colitis (kind) Diverticulosis or Diverticulitis Emphysema Goitre Hepatitis Hypoglycemia (low blood sugar) lleitis (Regional) Malaria Nephritis Pancreatitis Pleurisy Pneumonia Pneumothorax Polyp Rheumatism Rheumatic Heart Disease Tuberculosis Tumors Typhoid-Paratyphoid Ulcers (Stomach or Duodenal) Uremia Venereal diseases (Syphilis, Gonorrhea, herpes, Chlymedia) Chronic Infectious Disease Fungus Skin Tumors Moles (Nevi) Pilonidal Cyst-Spine Dizziness (Vertigo) Frequent Fainting Head Injury Guillian-Barre Convulsions Stroke Meningitis Encephalitis Detached Retina Double vision Optic Neuritis Wear Hearing Aid Mastoid Infection Polyps of Nose Sinus Infection Persistent Hoarseness Are Your Teeth Good HAVE YOU EVER HAD: Yes No Underactive Thyroid Overactive Thyroid Infection of Thyroid Tumor of Thyroid Shortness of Breath Coughing Up Blood Embolism of Lungs Abscess in Lungs Collapsed Lung Tumor in Lungs High Blood Pressure Low Blood Pressure Heart Murmur (Leaking Valve) Chest Pain Angina Pectoris Heart Failure Swelling of Ankles Coronary Disease Heart Attack Enlarged Heart Hiatus Hernia Inability to Swallow Loss of Weight (unexplained) Bleeding of Stomach Perforation of Stomach Gastritis Gallstones Surgical Removal of Gallbladder Jaundice Abscess of Liver Enlarged Liver Neuritis Sciatica A Disc Problem Varicose Veins Spinal Curvature Back Trouble Deformities Amputation Paralysis Fractures Phlebitis Bones that Break Easily Bone or Muscle Tumor Bleeding or Clotting Problem Infection of Lymph Glands Hodgkin's Disease Appendicitis Appendectomy Obstruction (kink) of Intestines Intestinal Parasites Hernia (rupture) Hemorrhoids (piles) Bleeding from Rectum Fistula in Ano Infection of Kidneys Horseshoe Kidney Removal of Kidney Bleeding of Kidney Tumor of Kidney Infection of Bladder Stones in Bladder Bleeding of Bladder Tumor of Bladder Sugar in Urine Infection of Prostate Enlargement of Prostate Tumor of Prostate Prostate Removed Surgically Urethral Stricture Testicle Disease or Lumps Undescended Testicle Discharge from Penis Sore on Penis

To what extent have you consumed alcohol in the past? At the present time? Is there any history of alcoholism in your family? Yes No Have you ever sought help for an alcoholic problem? Yes No Have you had a recent blood test? Yes No Date: Chest x-ray? Yes No Date: E.K.G.? Yes No Date: Do you have any health problems not covered in the previous questions? Yes No If yes, please explain:   The Donor states that to the best of his/her knowledge the information given on these forms is correct. He is aware that BioCom does not assume responsibility for the accuracy of the answers provided by him.