JARIN Personal Health

ALLERGIES

Do you currently have No

any allergies?

Did you have any Yes

allergies in your
childhood?

Which allergy Mosquito bites

Reaction Rash

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 Football and Running

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?

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Have you ever had an ● Yes ● No
alcohol abuse?

Have you ever had a ● Yes ● No

drug abuse?

Do you smoke ● Yes ● No

cigarettes?

Do you have any ● Yes ● No

children?

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JARIN 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 0 5 1 1 1 1

FAMILY PROFILES

MOTHER

Limited Information Known

Year of birth 1967
Ethnicity German/French
Height 181
Weight 80
Eye color Blue
Hair color Light Brown
Skin color Fair (skin will tan lightly on sun exposure)
Occupation Retail Clerk
Education Retail Clerk Apprenticeship
Select if he/she is living or deceased Living

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FATHER

Limited Information Known

Year of birth 1965
Ethnicity Saudi Arabian/German
Height 177
Weight 80
Eye color Green
Hair color Black
Skin color Medium (light color but will tan moderate to dark)
Occupation Anaesthetist
Education Master's Degree in Human Medicine
Select if he/she is living or deceased Living

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BROTHER 1

Year of birth 1996

Relation half sibling maternal side
Height 197
Weight 100
Eye color Brown
Hair color Brown
Skin color Medium (light color but will tan moderate to dark)
Education Car Salesman Apprenticeship
Occupation Car Salesman
Select if he/she is living or deceased Living
Limited Information Known

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BROTHER 2

Year of birth 1998

Relation half sibling paternal side
Height 185
Weight 70
Eye color Brown
Hair color Brown
Skin color Medium (light color but will tan moderate to dark)
Education Studying Master's Degree in Philosophy
Occupation Student
Select if he/she is living or deceased Living
Limited Information Known

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BROTHER 3

Year of birth 2001

Relation half sibling paternal side
Height 175
Weight 70
Eye color Brown
Hair color Brown (Blond as kid)
Skin color Fair (skin will tan lightly on sun exposure)
Education Studying Master's Degree in Physics
Occupation Student
Select if he/she is living or deceased Living
Limited Information Known

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BROTHER 4

Year of birth 2005

Relation half sibling paternal side
Height 185
Weight 70
Eye color Brown
Hair color Brown
Skin color Medium (light color but will tan moderate to dark)
Education Studying at A-Level
Occupation Student
Select if he/she is living or deceased Living
Limited Information Known

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BROTHER 5

Year of birth 2007

Relation half sibling maternal side
Height 170
Weight 77
Eye color Brown
Hair color Light Brown
Skin color Fair (skin will tan lightly on sun exposure)
Education Secondary School Pupil
Occupation Student
Select if he/she is living or deceased Living
Limited Information Known

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MATERNAL GRANDMOTHER

Limited Information Known

Year of birth 1932
Ethnicity German
Height 177
Weight 80
Eye color Brown
Hair color Brown
Skin color Fair (skin will tan lightly on sun exposure)
Occupation Clerk
Education Secondary School
Select if he/she is living or deceased Deceased
Cause of death Sepsis
Age at time of death 78

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MATERNAL GRANDFATHER

Limited Information Known

Year of birth 1915
Ethnicity German/French
Height 183
Weight 80
Eye color Brown
Hair color Black
Skin color Fair (skin will tan lightly on sun exposure)
Occupation Salesman
Education Apprenticeship Salesman
Select if he/she is living or deceased Deceased
Cause of death Circulatory Failure
Age at time of death 83

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PATERNAL GRANDMOTHER

Limited Information Known

Year of birth 1941
Ethnicity German
Height 176
Weight 85
Eye color Brown
Hair color Brown
Skin color Fair (skin will tan lightly on sun exposure)
Occupation Nurse
Education Apprenticeship Nurse
Select if he/she is living or deceased Living

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PATERNAL GRANDFATHER

Limited Information Known

Year of birth 1934
Ethnicity Saudi Arabian
Height 178
Weight 85
Eye color Brown
Hair color Black
Skin color Medium (light color but will tan moderate to dark)
Occupation Salesman
Education Elementary School
Select if he/she is living or deceased Deceased
Cause of death Lung Infection
Age at time of death 84

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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 Maternal Aunts
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
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

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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