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Medical Health History Profile

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MEDICAL & HEALTH HISTORY PROFILE

ﻣﻠﻒ اﻟﺘﺎرﻳﺦ اﻟﻄﺒﻲ و اﻟﺼﺤﻲ

To be completed by the mother. Please answer the following questions and provide dates with further details below for all question(s) to which you answered Yes.

.ﻳﺘﻢ إﻛﻤﺎﻟﻪ ﻣﻦ ﻗﺒﻞ اﻷم. ﻳﺮﺟﻰ اﻹﺟﺎﺑﺔ ﻋﻠﻰ اﻷﺳﺌﻠﺔ اﻟﺘﺎﻟﻴﺔ و ﺗﻘﺪﻳﻢ اﻟﺘﻮارﻳﺦ واﻟﺘﻔﺎﺻﻴﻞ اﻷﺧﺮى ﻟﺠﻤﻴﻊ اﻷﺳﺌﻠﺔ اﻟﺘﻲ أﺟﺒﺖ ﻋﻠﻴﻬﺎ ﺑﻨﻌﻢ

Acknowledgement of Medical and Health History Profile

إﻗﺮار ﺑﻤﻠﻒ اﻟﺘﺎرﻳﺦ اﻟﻄﺒﻲ واﻟﺼﺤﻲ

After I have completed the Medical and Health History Profile, I certify that all the information I have provided to CellSave is true and correct to the best of my knowledge.

ﺑﻌﺪ أن أﻛﻤﻠﺖ ﻣﻠﻒ اﻟﺘﺎرﻳﺦ اﻟﻄﺒﻲ واﻟﺼﺤﻲ، أﻗﺮ ﺑﺄن ﺟﻤﻴﻊ اﻟﻤﻌﻠﻮﻣﺎت اﻟﺘﻲ ﻗﺪﻣﺘﻬﺎ إﻟﻰ ﺳﻴﻞ ﺳﻴﻒ ﺣﻘﻴﻘﻴﺔ وﺻﺤﻴﺤﺔ ﻋﻠﻰ ﺣﺪ ﻋﻠﻤﻲ.

Place:

اﻟﻤﻜﺎن:

Date:

اﻟﺘﺎرﻳﺦ:

Name:
MOTHER/LEGAL GUARDIAN FULL LEGAL NAME

اﻻﺳﻢ:
اﻻﺳﻢ اﻟﻘﺎﻧﻮﻧﻲ اﻟﻜﺎﻣﻞ ﻟﻸم / اﻟﻮﺻﻲ اﻟﻘﺎﻧﻮﻧﻲ

Health of the MOTHER and baby’s BIOLOGICAL FATHER

ﺻﺤﺔ اﻷم و ﺻﺤﺔ اﻷب اﻟﺒﻴﻮﻟﻮﺟﻲ ﻟﻠﻄﻔﻞ

Has anyone in your Maternal or Paternal Family:

هل يوجد أي شخص في عائلة الأم أو عائلة الأب :

Been diagnosed with: Aplastic Anemia, Fanconi Anemia, Thalassemia (Major or Minor), Chronic Granulomatosis Disease (CGD), Sickle Cell Anemia (Disease or Trait), Hunter Syndrome, Hurler Syndrome or any other storage disorder, Severe combined Immunodeficiency Syndrome or Blood/ Bleeding and Genetic disorders? Circle if applicable.

نعم/Yes لا/No

ﺗﻢ ﺗﺸﺨﻴﺺ إﺻﺎﺑﺘﻪ: ﺑﻔﻘﺮ اﻟﺪم اﻟﻼﺗﻨﺴﺠﻲ ، ﻓﻘﺮ اﻟﺪم ﻓﺎﻧﻜﻮﻧﻲ ، اﻟﺜﻼﺳﻴﻤﻴﺎ )اﻟﻜﺒﺮى أو اﻟﺜﺎﻧﻮﻳﺔ( ، ﻣﺮض اﻟﻮرم اﻟﺤﺒﻴﺒﻲ اﻟﻤﺰﻣﻦ (CGD) ، ﻓﻘﺮ اﻟﺪم اﻟﻤﻨﺠﻠﻲ (ﻣﺮض أو ﺳﻤﺔ) ، ﻣﺘﻼزﻣﺔ ﻫﻨﺘﺮ ، ﻣﺘﻼزﻣﺔ ﻫﻴﺮﻟﺮ أو أي اﺿﻄﺮاب ﺗﺨﺰﻳﻦ آﺧﺮ ، ﻣﺘﻼزﻣﺔ ﻧﻘﺺ اﻟﻤﻨﺎﻋﺔ اﻟﻤﺸﺘﺮﻛﺔ اﻟﺸﺪﻳﺪة أو اﻟﺪم / اﻟﻨﺰﻳﻒ واﻻﺿﻄﺮاﺑﺎت اﻟﻮراﺛﻴﺔ؟ ﺿﻊ داﺋﺮة إن أﻣﻜﻦ.

Had Creutzfeldt-Jakob Disease (CJD)?

نعم/Yes لا/No

كان لديه مرض كروتزفيلد جاكوب (CJD)؟

Have you or the baby’s biological father ever:

هل سبق لك أو للأب البيولوجي للطفل أن:

Been diagnosed with any form of Creutzfeldt-Jakob disease (CJD) or other Human Transmissible Spongiform Encephalopathy?

نعم/Yes لا/No

ﺗﻢ ﺗﺸﺨﻴﺺ إﺻﺎﺑﺘﻚ ﺑﺄي ﺷﻜﻞ ﻣﻦ أﺷﻜﺎل ﻣﺮض ﻛﺮوﺗﺰﻓﻴﻠﺪ ﺟﺎﻛﻮب (CJD) أو ﻏﻴﺮه ﻣﻦ اﻻﻋﺘﻼل اﻟﺪﻣﺎﻏﻲ اﻹﺳﻔﻨﺠﻲ اﻟﺒﺸﺮي اﻟﻘﺎﺑﻞ ﻟﻼﻧﺘﻘﺎل؟

Had a transplant or medical procedure involving exposure to organs, tissue or living cells from an animal?

نعم/Yes لا/No

ﺗﻢ ﺧﻀﻮﻋﻚ ﻟﻌﻤﻠﻴﺔ زرع أو إﺟﺮاء ﻃﺒﻲ ﻳﻨﻄﻮي ﻋﻠﻰ اﻟﺘﻌﺮض ﻷﻋﻀﺎء أو أﻧﺴﺠﺔ أو ﺧﻼﻳﺎ ﺣﻴﺔ ﻣﻦ ﺣﻴﻮان؟

Been deferred as blood donor for a reason other than anemia or being underweight?

نعم/Yes لا/No

ﺗﻢ ﺗﺄﺟﻴﻠﻚ ﻛﻤﺘﺒﺮع ﺑﺎﻟﺪم ﻟﺴﺒﺐ آﺧﺮ ﻏﻴﺮ ﻓﻘﺮ اﻟﺪم أو ﻧﻘﺺ اﻟﻮزن؟

Taken intravenous drugs not prescribed by a physician or had sexual contact with someone who has?

نعم/Yes لا/No

ﺗﻨﺎوﻟﺖ اﻷدوﻳﺔ ﻋﻦ ﻃﺮﻳﻖ اﻟﻮرﻳﺪ اﻟﺘﻲ ﻟﻢ ﻳﺼﻔﻬﺎ اﻟﻄﺒﻴﺐ أو ﻛﺎن ﻋﻠﻰ اﺗﺼﺎل ﺟﻨﺴﻲ ﻣﻊ ﺷﺨﺺ ﻗﺪ ﺗﻨﺎوﻟﻬﺎ؟

Since 1977, have you lived in Africa or had sexual contact with anyone who was born or lived in Africa?

نعم/Yes لا/No

ﻣﻨﺬ ﻋﺎم 1977، ﻋﺸﺖ ﻓﻲ أﻓﺮﻳﻘﻴﺎ أو ﺗﻢ اﺗﺼﺎل ﺟﻨﺴﻲ ﻣﻊ أي ﺷﺨﺺ وﻟﺪ أو ﻋﺎش ﻓﻲ أﻓﺮﻳﻘﻴﺎ؟

From 1980 through 1996, did you spend time that adds up to three (3) months or more in the United Kingdom? (Review list of countries in the UK)

نعم/Yes لا/No

ﻣﻦ ﻋﺎم 1980 ﺣﺘﻰ ﻋﺎم 1996 ، ﻗﻀﻴﺖ وﻗﺘﺎً ﻳﺼﻞ إﻟﻰ ﺛﻼﺛﺔ (3) أﺷﻬﺮ أو أﻛﺜﺮ ﻓﻲ اﻟﻤﻤﻠﻜﺔ اﻟﻤﺘﺤﺪة؟ (ﻣﺮاﺟﻌﺔ ﻗﺎﺋﻤﺔ اﻟﺒﻠﺪان ﻓﻲ اﻟﻤﻤﻠﻜﺔ اﻟﻤﺘﺤﺪة)

From 1980 to present did you spend time that adds up to five (5) years or more in Europe? (Review list of countries in Europe)

نعم/Yes لا/No

ﻣﻦ ﻋﺎم 1980 إﻟﻰ اﻟﻮﻗﺖ اﻟﺤﺎﺿﺮ، ﻗﻀﻴﺖ وﻗﺘﺎً ﻳﺼﻞ إﻟﻰ ﺧﻤﺲ (5) ﺳﻨﻮات أو أﻛﺜﺮ ﻓﻲ أوروﺑﺎ؟ (ﻣﺮاﺟﻌﺔ ﻗﺎﺋﻤﺔ اﻟﺒﻠﺪان ﻓﻲ أوروﺑﺎ)

From 1980 to present, did you receive a transfusion of blood or blood components in the United Kingdom or France? (Review list of countries in the UK)

نعم/Yes لا/No

ﻣﻦ ﻋﺎم 1980 إﻟﻰ اﻟﻮﻗﺖ اﻟﺤﺎﺿﺮ ، ﺗﻠﻘﻴﺖ ﻋﻤﻠﻴﺔ ﻧﻘﻞ دم أو ﻣﻜﻮﻧﺎت دم ﻓﻲ اﻟﻤﻤﻠﻜﺔ اﻟﻤﺘﺤﺪة أو ﻓﺮﻧﺴﺎ؟(ﻣﺮاﺟﻌﺔ ﻗﺎﺋﻤﺔ اﻟﺒﻠﺪان ﻓﻲ اﻟﻤﻤﻠﻜﺔ اﻟﻤﺘﺤﺪة)

Have you ever had babesiosis?

نعم/Yes لا/No

أصبت بداء البابيزيا؟

In the past 12 months have you or the baby's biological father:

ﺧﻼل ١٢ ﺷﻬﺮ اﻟﻤﺎﺿﻴﺔ ﻫﻞ اﻧﺘﻲ او اﻟﻮاﻟﺪ اﻟﺒﻴﻮﻟﻮﺟﻲ ﻟﻠﻄﻔﻞ:

Received blood or blood factor products, derivatives or a tissue organ transplant?

نعم/Yes لا/No

ﺗﻠﻘﻴﺖ دم أو ﻋﻼﺟﺎت ﻟﺘﺠﻠﻂ اﻟﺪم، أو زرع أﻋﻀﺎء اﻷﻧﺴﺠﺔ ؟

Come into contact with someone else's blood? (E.g. accidental needle stick)?

نعم/Yes لا/No

ﺗﻢ إﺗﺼﺎل دﻣﻚ ﺑﺪم ﺷﺨﺺ آﺧﺮ؟ (إﺑﺮة)

Had a tattoo, piercing (any type), acupuncture or had a needle gun used on you?

نعم/Yes لا/No

ﺗﻢ ﻗﻴﺎﻣﻚ ﺑﻮﺷﻢ، أو أي ﻧﻮع ﻣﻦ اﻟﺜﻘﻮب، أو اﻟﻮﺧﺰ ﺑﺎﻷﺑﺮ؟

Received shots, vaccinations, including RH immune Globulin?

نعم/Yes لا/No

ﺗﻠﻘﻴﺖ ﻟﻘﺎﺣﺎت، ﺗﺘﻀﻤﻦ Rh اﻟﺠﻠﻮﺑﻴﻮﻟﻴﻦ اﻟﻤﻨﺎﻋﻲ؟

Been diagnosed with West Nile Virus?

نعم/Yes لا/No

أﺻﺒﺖ ﺑﻔﻴﺮوس ﻏﺮب اﻟﻨﻴﻞ؟

Traveled to an area with an increased risk for West Nile Virus transmission?

نعم/Yes لا/No

ﻫﻞ ﺳﺎﻓﺮت إﻟﻰ ﻣﻨﻄﻘﺔ ﻳﺰداد ﻓﻴﻬﺎ ﺧﻄﺮ اﻧﺘﻘﺎل ﻓﻴﺮوس ﻏﺮب اﻟﻨﻴﻞ؟

Had sexual contact with someone with Hepatitis, Jaudice or HIV?

نعم/Yes لا/No

ﻛﻨﺖ ﻋﻠﻰ اﺗﺼﺎل ﺟﻨﺴﻲ ﻣﻊ ﺷﺨﺺ ﻣﺼﺎب ﺑﺎﻟﺘﻬﺎب اﻟﻜﺒﺪ أو اﻟﻴﺮﻗﺎن أو ﻓﻴﺮوس ﻧﻘﺺ اﻟﻤﻨﺎﻋﺔ اﻟﺒﺸﺮﻳﺔ؟

Had sexual contact with anyone who has hemophilia or has used clotting factor concentrats?

نعم/Yes لا/No

ﻛﻨﺖ ﻋﻠﻰ اﺗﺼﺎل ﺟﻨﺴﻲ ﻣﻊ أي ﺷﺨﺺ ﻣﺼﺎب ﺑﺎﻟﻬﻴﻤﻮﻓﻴﻠﻴﺎ أو اﺳﺘﺨﺪم ﻣﺮﻛﺰات اﻟﺘﺨﺜﺮ؟

Had an accidental needle-stick?

نعم/Yes لا/No

ﺗﻢ ﺗﻌﺮﺿﻚ ﻟﻮﺧﺰ أﺑﺮة ﺑﺎﻟﺨﻄﺄ ؟

Been in jail or prison for more than 72 hours?

نعم/Yes لا/No

تم تواجدك في السجن لأكثر من 72 ساعة؟

Are you currently:

ﻫﻞ اﻧﺖ ﺣﺎﻟﻴﺎ:

In a good general health? If No, please explain:

نعم/Yes لا/No

ﻓﻲ ﺻﺤﺔ ﻋﺎﻣﺔ ﺟﻴﺪة؟ اذا ﻻ، ﻳﺮﺟﻰ اﻟﺘﻔﺴﻴﺮ:

Suffering from any chronic diseases? If Yes, please specify:

نعم/Yes لا/No

ﺗﻌﺎﻧﻲ ﻣﻦ أي أﻣﺮاض ﻣﺰﻣﻨﺔ؟ اذا ﻧﻌﻢ، ﻳﺮﺟﻰ اﻟﺘﺤﺪﻳﺪ:

Taking any prescribed medication/s? If Yes, please specify:

نعم/Yes لا/No

ﺗﺘﻨﺎوﻟﻲ أي ﻣﻦ اﻷدوﻳﺔ اﻟﻤﻮﺻﻮﻓﺔ ﻃﺒﻴﺎً؟ اذا ﻧﻌﻢ، ﻳﺮﺟﻰ اﻟﺘﺤﺪﻳﺪ:

Having planned cesarean delivery?

نعم/Yes لا/No

ﻣﺨﻄﻂ ﻗﻴﺼﺮﻳﺔ وﻻدة ﻟﺪﻳﻚ ﻟﻬﺎ؟

Having any infectious skin disease? (N/A for father)

نعم/Yes لا/No

ﻟﺪﻳﻚ أي ﻣﺮض ﺟﻠﺪي ﻣﻌﺪي؟ (ﻻ ﻳﻨﻄﺒﻖ ﻋﻠﻰ اﻷب)

Having any complications or medical conditions that could be affected adversely by the collection procedure? (E.g. Cancer, Blood Diseases, Lung Disease, Bleeding Problems, Heart Disease, Chest Pain, Stroke, Seizure or Multiple Sclerosis).

نعم/Yes لا/No

ﺗﻌﺎﻧﻲ ﻣﻦ أي ﻣﺸﺎﻛﻞ أو ﺣﺎﻻت ﻃﺒﻴﺔ اﻟﺘﻲ ﻳﻤﻜﻦ أن ﺗﺘﺄﺛﺮ ﺳﻠﺒًﺎ ﺑﺈﺟﺮاء اﻟﺘﺠﻤﻴﻊ. (ﻣﺜﻞ اﻟﺴﺮﻃﺎن, أﻣﺮاض اﻟﺪم, أﻣﺮاض اﻟﺮﺋﺔ, ﻣﺸﺎﻛﻞ اﻟﻨﺰﻳﻒ, أﻣﺮاض اﻟﻘﻠﺐ, أﻟﻢ اﻟﺼﺪر, ﺳﻜﺘﺔ دﻣﺎﻏﻴﺔ, اﻟﻨﻮﺑﺎت أو اﻟﺘﺼﻠﺐ اﻟﻤﺘﻌﺪد.)

Within the last month have you:

ﺧﻼل اﻟﺸﻬﺮ اﻟﻤﺎﺿﻲ ﻫﻞ:

Taken Accutane (isotretinion) or Proscar for skin or hair?

نعم/Yes لا/No

ﺗﻨﺎوﻟﺖ أي ﻣﻦ اﻛﻮﺗﺎﻧﻲ (آﻳﺰوﺗﺮﻳﺘﻴﻨﻮﻳﻦ) أو ﺑﺮوﺳﻜﺎر ﻟﻠﺠﻠﺪ او ﻟﻠﺸﻌﺮ؟

Taken any live vaccines (Measles, Mumps)?

نعم/Yes لا/No

ﺗﻨﺎوﻟﺖ أي ﻟﻘﺎﺣﺎت ﺣﻴﺔ ﻣﺜﻞ ﻟﻘﺎح اﻟﺤﺼﺒﺔ و ﻟﻘﺎح اﻟﻨﻜﺎف؟

Had any chemotherapy (during pregnancy)? (N/A for father)

نعم/Yes لا/No

ﻛﺎن ﻟﺪﻳﻚ أي ﻋﻼج ﻛﻴﻤﻴﺎﺋﻲ (ﺧﻼل اﻟﺤﻤﻞ)؟ (ﻻ ﻳﻨﻄﺒﻖ ﻋﻠﻰ اﻷب)

In the past 6 months have you:

ﺧﻼل ٦ أﺷﻬﺮ اﻟﻤﺎﺿﻴﺔ ﻫﻞ:

Been bitten by an animal suspected of having rabies?

نعم/Yes لا/No

ﺗﻌﺮﺿﺖ ﻟﻌﻀﺔ ﺣﻴﻮان ﻳﺸﺘﺒﻪ ﻓﻲ إﺻﺎﺑﺘﻪ ﺑﺪاء اﻟﻜﻼب؟

Has the mother traveled outside of UAE? If yes, please mention where and when:

نعم/Yes لا/No

ﻫﻞ ﺳﺎﻓﺮت اﻷم ﺧﺎرج دوﻟﺔ اﻹﻣﺎرات اﻟﻌﺮﺑﻴﺔ اﻟﻤﺘﺤﺪة؟ إذا ﻛﺎﻧﺖ اﻹﺟﺎﺑﺔ ﻧﻌﻢ، ﻳﺮﺟﻰ ذﻛﺮ أﻳﻦ وﻣﺘﻰ:

In the past 12 months or during pregnancy have you:

ﺧﻼل ٢ ١ ﺷﻬﺮ اﻟﻤﺎﺿﻲ ﻫﻞ :

Taken any Immune Globulin? (Not Rh Immune Globulin)

نعم/Yes لا/No

ﺗﻨﺎوﻟﺖ اﻟﺠﻠﻮﺑﻴﻮﻟﻴﻦ اﻟﻤﻨﺎﻋﻲ؟ (ﻟﻴﺲ Rh اﻟﺠﻠﻮﺑﻴﻮﻟﻴﻦ اﻟﻤﻨﺎﻋﻲ)

Taken any experimental medications/vaccines?

نعم/Yes لا/No

ﺗﻠﻘﻴﺖ أي أدوﻳﺔ ﺗﺠﺮﻳﺒﻴﺔ\ﻟﻘﺎﺣﺎت؟

Taken Rabies Vaccine - for exposure?

نعم/Yes لا/No

ﺗﻠﻘﻴﺖ ﻟﻘﺎح داء اﻟﻜﻠﺐ - اﻟﺘﻌﺮض ﻟﻠﻌﺪوى؟

Had a medical diagnosis of a Zika virus infection?

نعم/Yes لا/No

ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﻃﺒﻴًﺎ ﺑﻌﺪوى ﻓﻴﺮوس زﻳﻜﺎ؟

Lived in or traveled to an area with an increased risk for Zika virus transmission?

نعم/Yes لا/No

ﻛﻨﺖ ﺗﻌﻴﺶ أو ﺳﺎﻓﺮت إﻟﻰ ﻣﻨﻄﻘﺔ ﻳﺰداد ﻓﻴﻬﺎ ﺧﻄﺮ اﻧﺘﻘﺎل ﻓﻴﺮوس زﻳﻜﺎ؟

Within the past 3 years have you:

ﺧﻼل ٣ ﺳﻨﻮات اﻟﻤﺎﺿﻴﺔ ﻫﻞ:

Taken Soriatane (acitretin) or Tegison (etretinate) - for psoriases?

نعم/Yes لا/No

اﺧﺬت ﺳﻮرﻳﺎﺗﺎن (أﺳﻴﺘﺮﻳﺘﻴﻦ) أو ﺗﻴﺠﻴﺴﻮن (إﺗﺮﻳﺘﻴﻨﻴﺖ) - ﻟﻌﻼج اﻟﺼﺪﻓﻴﺔ؟

Have you ever:

ﻫﻞ ﺳﺒﻖ ﻟﻚ أن :

Taken insulin from a Cow Source?

نعم/Yes لا/No

ﺗﻠﻘﻴﺖ اﻷﻧﺴﻮﻟﻴﻦ ﻣﻦ ﻣﺼﺪر ﺑﻘﺮي؟

Taken Growth Hormone from human Pituitary Glands (not infertility hormones)

نعم/Yes لا/No

ﺗﻠﻘﻴﺖ ﻫﺮﻣﻮن اﻟﻨﻤﻮ ﻣﻦ اﻟﻐﺪد اﻟﻨﺨﺎﻣﻴﺔ اﻟﺒﺸﺮﻳﺔ (وﻟﻴﺲ ﻫﺮﻣﻮﻧﺎت اﻟﻌﻘﻢ)؟

Been diagnosed with Sepsis or Bacteremia?

نعم/Yes لا/No

ﺗﻢ ﺗﺸﺨﻴﺼﻚ ﺑﺎﻹﻧﺘﺎن أو ﺗﺠﺮﺛﻢ اﻟﺪم؟

Been diagnosed with, or tested positive for HIV HLTV, Syphilis, Hepatitis B or C? Type if applicable.

نعم/Yes لا/No

ﺗﻢ ﺗﺸﺨﻴﺼﻚ أو اﺧﺘﺒﺎرك إﻳﺠﺎﺑﻴﺎ ﻟﻔﻴﺮوس ﻧﻘﺺ اﻟﻤﻨﺎﻋﺔ اﻟﺒﺸﺮﻳﺔ HLTV أو اﻟﺰﻫﺮي أو اﻟﺘﻬﺎب اﻟﻜﺒﺪ B أو C؟أكتب إن أمكن.

Been significantly exposed to substances that may be transferred in toxic amounts (Lead, Mercury)?

نعم/Yes لا/No

ﺗﻌﺮﺿﺖ ﺑﺸﻜﻞ ﻛﺒﻴﺮ ﻟﻠﻤﻮاد اﻟﺴﺎﻣﺔ (اﻟﺮﺻﺎص واﻟﺰﺋﺒﻖ)؟

Been diagnosed with Tuberculosis, Malaria, Chagas disease or Babesiosis or do you have acute respiratory disease?

نعم/Yes لا/No

ﺗﻢ ﺗﺸﺨﻴﺺ إﺻﺎﺑﺘﻚ ﺑﺎﻟﺴﻞ أو اﻟﻤﻼرﻳﺎ أو ﻣﺮض ﺷﺎﻏﺎس أو داء اﻟﺒﺎﺑﻴﺰﻳﺎ أو ﻟﺪﻳﻚ ﻣﺮض ﺗﻨﻔﺴﻲ ﺣﺎد؟

Had head or brain surgery with a transplant of brain covering (dura mater)?

نعم/Yes لا/No

ﺧﻀﻌﺖ ﻟﻌﻤﻠﻴﺔ ﺟﺮاﺣﻴﺔ ﻓﻲ اﻟﺮأس أو اﻟﺪﻣﺎغ ﻣﻊ زراﻋﺔ ﻏﻄﺎء اﻟﺪﻣﺎغ (اﻷم اﻟﺠﺎﻓﻴﺔ)؟

If you have selected “YES” in any of the questions listed in the Medical and Health History Profile, please explain below:

MEDICAL DIRECTOR(for CellSave use only)

Is the donor eligible according to defined risk-based clinical criteria? ○ Yes ○ No

MHHP updated (if obtained within 7 days of CB collection)? ○ Yes ○ No

24-HOUR CUSTOMER SERVICE
800 - CRYO | www.cellsave.com

B.2.02-01-1A-03

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January 22, 2026 10:23 pm +04

Medical Health History Profile Uploaded by Agedefy Bio - it@agedefy.bio IP 87.201.5.1