ERTAN 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?

Are you Nearsighted

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 Squash

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?

How many pr. day? 2

How long have you been 2

smoking? (years)

Do you have any ● Yes ● No

children?

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ERTAN 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 2 1 1 1 1

FAMILY PROFILES

MOTHER

Limited Information Known

Year of birth 1961
Ethnicity Finnish
Height 165
Weight 75
Eye color Blue
Hair color Blond
Skin color Fair (skin will tan lightly on sun exposure)
Occupation Homemaker
Education Business School
Select if he/she is living or deceased Living

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FATHER

Limited Information Known

Year of birth 1948
Ethnicity Polish
Height 175
Weight 80
Eye color Brown
Hair color Black
Skin color Medium (light color but will tan moderate to dark)
Occupation Banker
Education Business School
Select if he/she is living or deceased Living

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BROTHER 1

Year of birth 1992

Relation Full sibling
Height 190
Weight 85
Eye color Brown
Hair color Light Brown
Skin color Fair (skin will tan lightly on sun exposure)
Education Engineering School
Occupation Student
Select if he/she is living or deceased Living
Limited Information Known

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BROTHER 2

Year of birth 1995

Relation Full sibling
Height 183
Weight 90
Eye color Brown
Hair color Light Brown
Skin color Very fair (little to no ability to tan on sun exposure)
Education Art School
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 1934
Ethnicity Finnish
Height 160
Weight 60
Eye color Blue
Hair color Blond
Skin color Fair (skin will tan lightly on sun exposure)
Occupation Shop Owner
Education Primary School
Select if he/she is living or deceased Living

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MATERNAL GRANDFATHER

Limited Information Known 1

Limited Information Explanation He died before I was born
Year of birth 1930
Select if he/she is living or deceased Deceased
Cause of death Aneurism in the brain
Age at time of death 56

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PATERNAL GRANDMOTHER

Limited Information Known 1

Limited Information Explanation She died before I was born
Select if he/she is living or deceased Deceased
Cause of death Liver Cancer
Age at time of death 65

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PATERNAL GRANDFATHER

Limited Information Known 1

Limited Information Explanation He died before I was born
Select if he/she is living or deceased Deceased
Cause of death Arteriosclerosis
Age at time of death 74

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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 Father
D. blood clot in the brain ● Yes ● No Maternal Grandmother

She lost her sight on one eye afterwards

E. brain haemorrhage ● Yes ● No Maternal Grandfather
F. hypercholesterolaemia ● Yes ● No Father
G. other ● Yes ● No Paternal Grandfather

Arteriosclerosis

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 Father

Skin Cancer diagnosis at the age of 72

5. Stomach and intestines

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

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F. kidney cancer ● Yes ● No
G. other ● Yes ● No

7. Genital and breast

A. congenital genital malformations ● Yes ● No
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 Paternal Aunts

Type 2 Diabetes
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 You
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

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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
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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