Religion Born into: Personal Characteristics Height:
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6' 0"
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6' 6''
>6' 6''
Weight: Enter Weight: Build:
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Eye Color:
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Blue
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Brown
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Hazel
Other
Natural Hair Color:
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Auburn
Ashe Blonde
Strawberry Blonde
Blonde
Light Brown
Dark Brown
Black
Red
Do you wear corrective lenses: Are you predominantly: Skin Tone:
Select Skin Tone
Fair
Medium
Olive
Dark
Freckles:
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None
Few
Numerous
Additional Characteristics (check all that apply): Education/Work/Interests
Work/Occupation History Enter Occupation: What kind of work have you done in the past? What kind of work is most appealing to you? Personal Preferences/Abilities: Are you skilled mechanically or technically? How would you rate your Abilities in Mathematics: Literary Skills: Scientific/Research Ability: Athletic Abilities Do you have a favorite sport? Please list your favorite sports: How would you rate your Musical Skills/Ability: Artistic Talents:
Do you have any special talents or hobbies? If yes, please list your talents or hobbies: How would you describe your personality? What is your ultimate ambition in life? Social History Tobacco (Check all that currently apply): Alcohol Drug usage: Enter usages:
Have you ever used injectable drugs?
If yes, when did you last use injectable drugs? Sexual Behavior: The Law (check all that apply): If yes, explain the type of legal trouble you have had: Crimes: What was the crime you were convicted of perpetrating? Psychological History: Have you ever sought counseling for depression or emotional problems? Have you ever taken antidepressants for more than three months at a time?
Have you ever been diagnosed as
having any of the following (please check all that apply)
Personal Health History: Do you have any allergies that you're aware of? If yes, please indicate what you are allergic to: Are you allergic to any medications? If yes, please tell us what medication you're allergic to: Were you or any of your relatives born with genetic disorders that led to hearing impairment? Do you have any dietary restrictions? If yes, what are your dietary restrictions, and for what reason? Do you take any supplemental vitamins or herbal remedies on a continual basis? If yes, please list what vitamins or herbal remedies you are taking: Do you take any prescription or over the counter medication on a regular or continual basis? If yes, please list what medication you are currently taking: Do you exercise regularly? Have you had any surgeries in the past? If yes, please indicate what surgeries you have had: Have you ever had an adverse reaction to general anesthetics? If yes, please indicate what happened, and the severity of the response: Have you ever been hospitalized for anything other than the above listed surgeries? If yes, please tell us why you were hospitalized: Menstrual History: (please answer the following questions about your menstrual cycle) How old were you when you first began to menstruate: How many days are there (usually) between one period to the next? How many days do your periods usually last? Do you ever experience mid-cycle bleeding? Would you describe your menstrual cycle as: In general, how heavy is your menstrual flow? Have you ever taken, or are you currently taking oral contraceptives? If yes, what brand and for how long? What methods of contraceptive have you used? Please list: Sexual Activity/History: (please answer the following questions about your sexual history) How many sexual partners have you had intercourse with in the past year? Have you been with a sexual partner that is a known user of drugs? Have you had intercourse with a bisexual or homosexual partner? Have you had intercourse without the use of a condom in the last year? Have any of your past or present sexual partners shown evidence of having HIV infection? Have you ever been with a sexual partner who tested positive for a sexually transmitted disease? If you answered yes to any of the above questions, please explain in full detail: Pregnancy History: Have you ever been pregnant? If yes, how many times have you been pregnant?
Have you ever carried a pregnancy to term?
If yes, were there any complications with gestation or delivery? If yes, what were the complications? How many times have you given birth? Has every delivery resulted in a live birth?
Do you have an occupation with risk of exposure to radiation or other chemicals that could be harmful to your health? If yes, please explain what chemicals you are or have been exposed to: Have you had a Pap Smear within the past 6 months? Was result of your Pap Smear within normal limits?
What is your blood type?
Please Choose:
A positive
A negative
AB positive
AB negative
B positive
B negative
O positive
O negative
Not sure
Have you received a blood transfusion within the past six months? Have you ever received a blood transfusion or other blood products at any time in your life? If yes, when did this happen?
Are you a current or former U.S. military or civilian military employee (or dependent), who resided on a military base in Germany, Belgium, or The Netherlands for 6 months or more between 1980-1990?
Yes
Are you a current or former U.S. military or civilian military employee (or dependent), who resided on a military base in Greece, Turkey, Spain, Portugal, or Italy for 6 months or more between 1980-1996?
No
Have you ever spent 5 or more cumulative years in Europe?
Yes
No
Did you spend 3 or more cumulative months in the U.K. between 1980-1996?
Yes
No
Have you received any blood transfusions or transfusions of blood products in the U.K. or France?
Yes
No
Have you or your sexual partner lived in Cameroon, Central African Republic, Chad, Congo, Equatorial Guinea, Gabon, Niger, or Nigeria since 1977?
Yes
No
Have you ever received blood transfusions or other blood products in any of the African countries listed above?
Yes
No
Ever been diagnosed with dementia, or other diseases of the central nervous system?
Yes
No
Ever received a human pituitary-derived growth hormone?
Yes
No
Ever had a non-synthetic dura mater transplant?
Yes
No
Ever received any transplantation of living cells (xenotransplant), or had intimate
Yes
No
Have you acquired a tattoo within the last year? If yes, when did you get your newest tattoo? Have you ever had an animal bite or rabies? Have you ever received blood products or clotting factors for abnormal bleeding? Have you ever been excluded from blood donation? If yes, please explain when and why: Have you ever received Pituitary derived growth hormone?
