Background Questions:

1. Age:
    
2. Date of birth: mm/dd/yyyy
    
3. Marital status? Single Married Divorced Separated
    
4. Occupation?
    
5. What is your highest level of education?
    
6. Height: feet inches
    
7. Weight: lbs.
    
8. Eye color: Blue  Brown  Green  Hazel
    
9. Natural hair color: Black  Brown  Blonde  Red
    
10. Ethnic background (e.g., German, French)?
     
11. Have you ever been pregnant? 
    No Yes
    How many times?
     
12. Have you ever been hospitalized (excluding childbirth)? 
    No Yes
    (When/Why)
     
13. Do you, or any member of your family, have any history of congenital abnormalities or genetic disease that run in your family? Please be specific.
    No Yes
    (Who/What)
     
14. Are you currently taking any medication? 
    No Yes
    (Type)