DEJAN Personal Health

ALLERGIES

Do you currently have No

any allergies?

VISION

Do you wear glasses or ● Yes ● No

corrective lenses?

HEARING

Do you have any hearing ● Yes ● No

impairments?

DIET & EXERCISE

Your diet is Good

Any dietary restrictions? No

Dietary supplements No
(vitamins, etc.)?

How often do you Occasionally

exercise?

Type of exercise Running cycling

HOSPITALISATION AND DISEASE HISTORY

Have you ever had ● Yes ● No

surgery?

Have you had any ● Yes ● No

hospitalization not
already mentioned?

Have you had major ● Yes ● No

x-ray exposure or other
radiation exposure?

NSU (non-specific ● Yes ● No

urethritis)

Chlamydia ● Yes ● No
Genital Warts (HPV) ● Yes ● No
Genital Herpes ● Yes ● No
Other(s) ● Yes ● No
Have you ever been ● Yes ● No
treated for any

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sexually-transmitted
disease(s)?

Have you ever had any ● Yes ● No

major illnesses such as
amoebic dysentery,
hepatitis, pneumonia,
mononucleosis, etc.?

Do you have any chronic ● Yes ● No

medical problems or
conditions?

Have you ever been ● Yes ● No

exposed to herbicides or
toxic chemicals?

Have you ever served in ● Yes ● No

the military?

Do you take any ● Yes ● No

medication or drugs,
including pain relievers
or recreational drugs

How many alcoholic ●0 ●1 ●2 ●3 ●4 ●5 ●6 ● 7+

drinks do you consume
during an average
week?

Have you ever had an ● Yes ● No

alcohol abuse?

Have you receieved any ● Yes ● No

treatment?

Do you smoke ● Yes ● No

cigarettes?

Do you have any ● Yes ● No

children?

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DEJAN Family Medical History

In this section you’ll learn about the donor’s family, including his parents,
grandparents, and any siblings. For each family member, the donor has detailed age,
appearance, occupation, personality, skills and health. Further down in the section,
you can also find specific information on any medical problems such as
cardiovascular, blood, respiratory, skin, neurological etc.
OVERVIEW

RELATIVES MOTHER FATHER SIBLINGS GRANDPARENTS

F M MGM MGF PGM PGF

NUMBER OF RELATIVES 1 1 1 1 1 1 1 1

FAMILY PROFILES

MOTHER

Limited Information Known

Year of birth 1960
Country of birth Nepal
Racial Group/Color Code Asian/Yellow
Height 167
Weight 72
Eye color Brown
Hair color Black
Skin color Medium (light color but will tan moderate to dark)
Occupation School Teacher
Education University Graduate
Select if he/she is living or deceased Living

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FATHER

Year of birth 1952

Country of birth Nepal
Racial Group/Color Code Asian/Yellow
Height 170
Weight 70
Eye color Brown
Hair color Black
Skin color Medium (light color but will tan moderate to dark)
Occupation veterinary doctor
Education University Degree
Select if he/she is living or deceased Living

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SISTER 1

Year of birth 1990

Relation Full sibling
Height 166
Weight 48
Eye color Brown
Hair color Black
Skin color Medium (light color but will tan moderate to dark)
Education High School
Occupation Student
Select if he/she is living or deceased Living

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BROTHER 1

Year of birth 1985

Relation Full sibling
Height 170
Weight 57
Eye color Brown
Hair color Black
Skin color Medium (light color but will tan moderate to dark)
Education High School
Occupation Army Officer
Select if he/she is living or deceased Living

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MATERNAL GRANDMOTHER

Year of birth 1940

Country of birth Nepal
Racial Group/Color Code Asian/Yellow
Height 167
Weight 75
Eye color Brown
Hair color Black
Skin color Fair (skin will tan lightly on sun exposure)
Occupation Housewife
Education No
Select if he/she is living or deceased Living

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MATERNAL GRANDFATHER

Year of birth 1933

Country of birth Nepal
Racial Group/Color Code Asian/Yellow
Height 178
Weight 65
Eye color Brown
Hair color Black
Skin color Fair (skin will tan lightly on sun exposure)
Occupation Farmer
Education Primary School
Select if he/she is living or deceased Living

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PATERNAL GRANDMOTHER

Year of birth 1936

Country of birth Nepal
Racial Group/Color Code Asian/Yellow
Height 165
Weight 78
Eye color Brown
Hair color Black
Skin color Medium (light color but will tan moderate to dark)
Occupation Housewife
Education No
Select if he/she is living or deceased Living

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PATERNAL GRANDFATHER

Year of birth 1936

Country of birth Nepal
Racial Group/Color Code Asian/Yellow
Height 172
Weight 61
Eye color Brown
Hair color Black
Skin color Medium (light color but will tan moderate to dark)
Occupation Farmer
Education No
Select if he/she is living or deceased Living

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FAMILY MEDICAL SUMMARY

Donor provided specific information on any medical problems affecting direct family members. The conditions reviewed are
summarised in the table below. If the the donor answered yes to any of the medical problems listed, he was asked to detail which
family member was affected and how.

Circulatory system
● Yes ● No

Gastrointestinal system
● Yes ● No

Genital/urinary system
● Yes ● No

Metabolic (hormones, enzymes, etc.)

● Yes ● No

Nervous system (brain, spinal cord, etc.)

● Yes ● No

Respiratory system
● Yes ● No

Skeletal system (bones, joints, muscles)

● Yes ● No

Organ (heart, lung, kidney, etc.)

● Yes ● No

Other
● None

Do you have any brothers or sisters who died in infancy or childhood?

● Yes ● No

Are there any diseases or abnormalities that appear to run in your family?
● Yes ● No

Has anyone in your family, including yourself, experienced recurring and/or chronic symptoms that have not been
evaluated by a physician? (Please include those symptoms that you may not consider serious.)
● Yes ● No

1. Heart and vessels

A. congenital heart malformations ● Yes ● No
B. arteriosclerosis ● Yes ● No
C. high blood pressure ● Yes ● No Maternal Grandfather
G. other ● Yes ● No
My Maternal Grandfather has high blood pressure, but he is still alive and doing good

2. Blood
A. leukemia ● Yes ● No
C. other ● Yes ● No

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3. Respiratory (lungs)
A. hay fever ● Yes ● No
B. asthma ● Yes ● No
C. emphysema ● Yes ● No
E. other ● Yes ● No

4. Skin
B. eczema ● Yes ● No
D. pigmentation disorders ● Yes ● No
F. other ● Yes ● No

5. Stomach and intestines

B. ulcerative colitis ● Yes ● No
C. Crohn's disease ● Yes ● No
G. other ● Yes ● No

6. Kidney and bladder

G. other ● Yes ● No

7. Genital and breast

B. undescended testicle ● Yes ● No
C. prostate cancer ● Yes ● No
D. cancer of uterus ● Yes ● No
E. breast cancer ● Yes ● No
F. ovarian cancer ● Yes ● No
G. other ● Yes ● No

8. Metabolic
B. diabetes mellitus ● Yes ● No Paternal Aunts
E. adrenal dysfunction or disorder ● Yes ● No
F. thyroid cancer ● Yes ● No
G. other ● Yes ● No
Diabetic Mellitus 2

9. Brain
B. migraines ● Yes ● No
C. multiple sclerosis ● Yes ● No
D. mental retardation ● Yes ● No
E. epilepsy or seizure disorder ● Yes ● No
G. Alzheimer's disease ● Yes ● No
K. other ● Yes ● No

10. Mental
A. schizophrenia ● Yes ● No
C. depression ● Yes ● No
F. other ● Yes ● No

11. Muscles/Bones/Joints
D. osteoporosis ● Yes ● No
E. deformity of spine ● Yes ● No
F. other ● Yes ● No

12. Vision and hearing

C. blindness ● Yes ● No
E. color blindness ● Yes ● No

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F. cataracts ● Yes ● No
G. glaucoma ● Yes ● No
J. deafness ● Yes ● No
K. other ● Yes ● No

13. Other
A. any other cancer not mentioned above ● Yes ● No
B. any other condition/disease not mentioned above ● Yes ● No

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