AKIM Personal Health

ALLERGIES

Do you currently have No

any allergies?

Did you have any No

allergies in your
childhood?

VISION

Do you wear glasses or ● Yes ● No

corrective lenses?

Have you undergone ● Yes ● No

corrective eye surgery?
HEARING

Do you have any hearing ● Yes ● No

impairments?

DIET & EXERCISE

How often do you Occasionally

exercise?

Type of exercise Weight lifting

HOSPITALISATION AND DISEASE HISTORY

Have you ever had ● Yes ● No

surgery?

Have you had any ● Yes ● No

hospitalization not
already mentioned?

Do you have any chronic ● Yes ● No

medical problems or
conditions?

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?

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Have you ever had a ● Yes ● No
drug abuse?

Do you smoke ● Yes ● No

cigarettes?

How many pr. day? 6

How long have you been 5

smoking? (years)

Do you have any ● Yes ● No

children?

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AKIM 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 0 1 1 1 1

FAMILY PROFILES

MOTHER

Limited Information Known

Year of birth 1974
Ethnicity Bulgarian
Height 178
Weight 90
Eye color Brown
Hair color Black
Skin color Fair (skin will tan lightly on sun exposure)
Occupation Chef
Education Chef
Select if he/she is living or deceased Living

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FATHER

Limited Information Known

Year of birth 1966
Ethnicity Bulgarian
Height 180
Weight 70
Eye color Brown
Hair color Black
Skin color Fair (skin will tan lightly on sun exposure)
Occupation Electrical plant manager
Education Electrical technician
Select if he/she is living or deceased Living

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SISTER 1

Year of birth 1996

Relation Full sibling
Height 170
Weight 50
Eye color Brown
Hair color Brown
Skin color Fair (skin will tan lightly on sun exposure)
Education University, archeology
Occupation Master's degree in politics
Select if he/she is living or deceased Living
Limited Information Known

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MATERNAL GRANDMOTHER

Limited Information Known

Year of birth 1950
Ethnicity Bulgarian
Height 170
Weight 80
Eye color Brown
Hair color Black
Skin color Fair (skin will tan lightly on sun exposure)
Occupation Cleaning assistant
Education High school
Select if he/she is living or deceased Deceased
Cause of death Natural
Age at time of death 60

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MATERNAL GRANDFATHER

Limited Information Known

Year of birth 1945
Ethnicity Bulgarian
Height 184
Weight 85
Eye color Brown
Hair color Black
Skin color Fair (skin will tan lightly on sun exposure)
Occupation Miner
Education High school
Select if he/she is living or deceased Deceased
Cause of death Natural
Age at time of death 72

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PATERNAL GRANDMOTHER

Limited Information Known

Year of birth 1943
Ethnicity Bulgarian
Height 168
Weight 52
Eye color Brown
Hair color Dark Brown
Skin color Fair (skin will tan lightly on sun exposure)
Occupation Doctor and a politician
Education Doctor
Select if he/she is living or deceased Living

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PATERNAL GRANDFATHER

Limited Information Known

Year of birth 1941
Ethnicity Bulgarian
Height 182
Weight 95
Eye color Brown
Hair color Black
Skin color Fair (skin will tan lightly on sun exposure)
Occupation Miner
Education High school
Select if he/she is living or deceased Deceased
Cause of death Gastric cancer
Age at time of death 79

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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.

1. Heart and vessels

A. congenital heart malformations ● Yes ● No
B. blood clot in the heart ● Yes ● No
C. high blood pressure ● Yes ● No
D. blood clot in the brain ● Yes ● No
E. brain haemorrhage ● Yes ● No
F. hypercholesterolaemia ● Yes ● No
G. other ● Yes ● No

2. Blood
A. leukemia ● Yes ● No
B. malignant lymphoma ● Yes ● No
C. other ● Yes ● No

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

4. Skin
A. congenital skin disorder ● Yes ● No
B. eczema ● Yes ● No
C. psoriasis ● Yes ● No
D. pigmentation disorders ● Yes ● No
E. malignant melanoma ● Yes ● No
F. other ● Yes ● No

5. Stomach and intestines

A. congenital gastrointestinal malformations ● Yes ● No
B. ulcerative colitis ● Yes ● No
C. Crohn's disease ● Yes ● No
D. gastric cancer ● Yes ● No Paternal Grandfather
E. pancreatic cancer ● Yes ● No
F. liver cancer ● Yes ● No
G. other ● Yes ● No

6. Kidney and bladder

A. congenital kidney malformations ● Yes ● No
B. congenital urinary tract malformations ● Yes ● No
C. hypospadias ● Yes ● No
D. polycystic kidney disease ● Yes ● No
E. kidney failure ● Yes ● No
F. kidney cancer ● Yes ● No
G. other ● Yes ● No

7. Genital and breast

A. congenital genital malformations ● Yes ● No

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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
A. inborn error of metabolism ● Yes ● No
B. diabetes mellitus ● Yes ● No
C. hyperthyroidism ● Yes ● No
D. hypothyroidism ● Yes ● No
E. adrenal dysfunction or disorder ● Yes ● No
F. thyroid cancer ● Yes ● No
G. other ● Yes ● No

9. Brain
A. congenital brain malformations ● Yes ● No
B. migraines ● Yes ● No
C. multiple sclerosis ● Yes ● No
D. mental retardation ● Yes ● No
E. epilepsy or seizure disorder ● Yes ● No
F. dyslexia ● Yes ● No
G. Alzheimer's disease ● Yes ● No
H. dementia ● Yes ● No
I. Parkinson's disease ● Yes ● No
J. brain cancer ● Yes ● No
K. other ● Yes ● No

10. Mental
A. schizophrenia ● Yes ● No
B. bipolar disease ● Yes ● No
C. depression ● Yes ● No
D. autism ● Yes ● No
E. ADHD ● Yes ● No
F. other ● Yes ● No

11. Muscles/Bones/Joints
A. congenital skeletal malformations ● Yes ● No
B. rheumatoid arthritis ● Yes ● No
C. cleft and/or lip palate ● Yes ● No
D. osteoporosis ● Yes ● No
E. deformity of spine ● Yes ● No
F. other ● Yes ● No

12. Vision and hearing

A. congenital eye malformations ● Yes ● No
B. congenital ear malformations ● Yes ● No
C. blindness ● Yes ● No
D. nystagmus ● Yes ● No
E. color blindness ● Yes ● No
F. cataracts ● Yes ● No
G. glaucoma ● Yes ● No
H. myopia (-7 or more) ● Yes ● No
I. retinal detachment ● Yes ● No

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J. deafness ● Yes ● No
K. other ● Yes ● No Paternal Grandfather

My grandfather was visually impaired. It was age-related.

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

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