Maternal Health Online Questionnaire - Cord For Life

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Maternal Health Questionnaire
Before you get started, there are some eligibility criteria for cord blood donation to check before you take the next step. Please be sure you meet the following requirements:
- You must be less than 34th week gestation to begin the application process
- You must be 18 years of age or older in order to donate your baby’s cord blood
- We cannot accept cord blood donations from multiple births (Acceptable for Private Storage-ONLY)
- If you and your physician have chosen to delay the clamping of the cord after your child’s birth (Acceptable for Private Storage-ONLY)
Mother's Information
NOTE IS IS IMPORTANT TO USE YOUR FULL LEGAL NAME ON ALL DOCUMENTS.
Mother's First Name*
Mother's Last Name*
Mother's M.I.
Last 4 SS# Digits*
Best Contact Phone:*
Email*
Mother’s DOB:*
MM slash DD slash YYYY
Address*
Street Address City State ZIP Code
Father's Information
Father's First Name*
Father's Last Name*
Father's M.I.
Last 4 SS# Digits (Optional)
Best Contact Phone:*
Email*
Father’s DOB:*
MM slash DD slash YYYY
Address*
Street Address City State ZIP Code
Physician Information
Delivery Physician’s Name*
Delivery Physician’s Phone*
Clinic Name*
Delivery Hospital Name*
Delivery Hospital Phone*
Hospital Address*
Street Address City State ZIP Code
Baby's Information
Since certain HLA Types may be more common in each ethic group; the information below will help in selecting a cord blood unit for transplant.
Baby’s Due Date*
MM slash DD slash YYYY
Baby’s Ethnicity*
Response is required, please check one
- Hispanic or Latino
- Not Hispanic or Latino
Baby's Race*
Response is required. Of which group(s) is your baby a member? (Select all that apply.)
- American Indian or Alaska Native
- Black or African American
- Asian
- Native Hawaiian or Other Pacific Islander
- White
American Indian or Alaska Native*
- Alaska Native or Aleut (ALANAM)
- North American Indian (AMIND)
- American Indian South or Central American (AMIND)
- Caribbean Indian (AMIND)
Black or African American*
- African (AFB)
- African American (AAFA)
- Black Caribbean (CARB)
- Black South or Central American (SCAMB)
Asian*
- Chinese (NCHI)
- Filipino (Philipino) (FILI)
- Japanese (JAPI)
- Korean (KORI)
- South Asian (SCSEAI)
- Vietnamese (SCSEAI)
- Other Southeast Asian (SCSEAI)
Native Hawaiian or Other Pacific Islander*
- Guamanian (OPI)
- Hawaiian (HAWI)
- Samoan (OPI)
- Other Pacific Islander (OPI)
White*
- Eastern European (CAU)
- Mediterranean (CAU)
- Middle Eastern (MENAFC)
- North Coast of Africa (MENAFC)
- North American (CAU)
- Northern European (CAU)
- Western European (CAU)
- White Caribbean (CAU)
- White South or Central American (CAU)
- Other White (CAU)

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Maternal Health Questions
Completion of all the requested information on this health questionnaire is required before a cord blood unit can be eligible for transplant. This is the only opportunity the cord blood center has to gather this important information from you. The questionnaire should be filled out privately by the expectant mother only, or in a private interview by an approved screener. An incomplete questionnaire will result in disqualification.

Your answers to these questions are confidential. Please refer to Cord For Life Notice of Privacy Practices. If after being accepted into this program or after your baby’s cord blood is collected, you learn of a reason which would exclude you from donating or feel that it should not be transfused to a patient, please call Cord For Life, Inc. You will not be penalized from withdrawing from the program, at any time.

Please read the following Health Questionnaire carefully. If you need help understanding any of the questions, please contact Cord For Life, Inc. at 1-800-869-8608 or 407-834-8333.
1. Have you ever donated or attempted to donate cord blood using your current or a different name to Cryobanks International, Lifeforce Cryobank Sciences, Inc. (LFC) or Cord For Life, Inc. (CFL)?*
- Yes
- No
Please provide details*
2. Have you, for any reason, been deferred or refused as a blood or cord blood donor, or been told not to donate blood or cord blood?*
- Yes
- No
Please explain reasons*
3. Have you taken any of the following medications*
(Check all that apply)
- Insulin from cows (bovine or beef insulin) since 1980?
- Growth hormone from human pituitary glands ever?
- None of the above
This field is hidden when viewing the form
3. Details*
- Yes
- No
4. In the past 8 weeks, have you had any shots or vaccinations?*
- Yes
- No
Please provide details*
5. In the past 12 weeks, have you had contact with someone who has received the smallpox vaccine?*
(Examples of contact include physical intimacy, touching the vaccination site, touching the bandages or covering the vaccination site, or handling bedding or clothing that had been in contact with an unbandaged vaccination site)
- Yes
- No
Please provide details*
6. In the past 4 months, have you experienced TWO (2) or more of the following: a fever (>100.5ºF or 38.6ºC), headache, muscle weakness, skin rash on trunk of the body, swollen lymph glands?*
- Yes
- No
Please provide details on which symptoms and when?*
7. Have you ever had any type of cancer, including leukemia?*
- Yes
- No
Please provide details*
8. During your pregnancy, have you been diagnosed with West Nile Virus or had a positive test for West Nile Virus?*
- Yes
- No
9. Have you ever had a past diagnosis of clinical, symptomatic viral hepatitis after age 11?*
- Yes
- No
Please provide details and dates*
10. Have you ever had a parasitic blood disease such as Leishmaniasis, Chagas disease or Babesiosis or any positive test for Chagas or T. cruzi, including screening tests?*
- Yes
- No

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Maternal Health Questions
Please read carefully and answer each of the following questions individually.
11. Have you ever been diagnosed with Creutzfeldt-Jakob Disease (CJD), Variant CJD, dementia, degenerative or demyelinating disease of the central nervous system, or other neurological disease where the cause is unknown?*
- Yes
- No
12. Have any of your blood relatives ever been diagnosed with Creutzfeldt-Jakob Disease (CJD), or have you been told that your family has an increased risk for CJD?*
- Yes
- No
13. Have you received a dura mater (brain covering) graft?*
- Yes
- No
14. Have you ever had a transplant or other medical procedure that involved being exposed to live cells, tissues, or organs from an animal?*
- Yes
- No
Please provide details*
15. Have you ever lived with or had sexual contact with anyone who had a transplant or other medical procedure that involved being exposed to live cells, tissues, or organs from an animal?*
- Yes
- No
Please provide details*
16. In the past 3 years, have you had malaria?*
- Yes
- No
Please provide details*
17. In the past 3 years, have you been outside the United States or Canada?*
- Yes
- No
Where*
When*
How Long*
18. In the past 12 months, have you had a blood transfusion?*
- Yes
- No
Please provide details*
19. In the past 12 months, have you had a transplant or tissue graft from someone other than yourself, such as organ, bone marrow, stem cell, cornea, bone, skin or other tissue?*
- Yes
- No
20. In the past 12 months, have you had a tattoo or piercing (ear, skin or body)?*
Please indicate type
- Yes
- No
Type*
- Tattoo
- Piercing
Details*
This field is hidden when viewing the form
21. Details
- Yes
- No
21. Were shared or non-sterile instruments, needles, or inks used for the tattoo or piercing?*
- Yes
- No

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Maternal Health Questions
Please read carefully and answer each of the following questions individually.
22. In the past 12 months, have you had an accidental needle stick or have you come into contact with someone else’s blood through an open wound (for example, a cut or sore), non-intact skin, or mucous membrane?*
(for example, into your eye, mouth, etc)?
- Yes
- No
Please provide details*
23. In the past 12 months, have you had or been treated for a sexually transmitted disease, including syphilis?*
- Yes
- No
Please provide details and dates.*
24. In the past 12 months have you given money, drugs, or other payment to anyone to have sex with you?*
- Yes
- No
25. In the past 12 months have you had sex with anyone who has taken money, drugs, or other payment in exchange for sex in the past 5 years?*
- Yes
- No
26. In the past 12 months, have you had sexual contact or lived with a person who has active or chronic viral hepatitis B or Hepatitis C?*
- Yes
- No
27. In the past 12 months, have you had sex, even once, with anyone who has used a needle to take drugs, steroids, or anything else not prescribed by a doctor in the past 5 years?*
- Yes
- No
28. In the past 12 months, have you had sex with a male who has had sex with another male, even once, in the past 5 years?*
- Yes
- No
29. In the past 12 months, have you had sex, even once, with anyone who has HIV/AIDS or had a positive test for the AIDS virus?*
- Yes
- No
30. In the past 12 months, have you been in juvenile detention, lockup, jail or prison for more than 72 continuous hours?*
- Yes
- No
31. In the past 5 years have you received money, drugs, or other payment for sex?*
- Yes
- No
32. In the past 5 years, have you used a needle, even once, to take drugs, steroids or anything else not prescribed for you by a doctor?*
- Yes
- No
33. Do you have AIDS or have you ever tested positive for HIV (including screening tests)?*
- Yes
- No
34. Do you have any of the following:*
Check all that apply.
- Unexplained night sweats?
- Unexplained blue or purple spots on or under the skin or mucous membranes?
- Unexplained weight loss?
- Unexplained persistent diarrhea?
- Unexplained cough or shortness of breath?
- Unexplained temperature higher than 100.5ºF (38.6ºC) for more than 10 days?
- Unexplained persistent white spots or sores in the mouth?
- Lumps in your neck, armpits, or groin lasting longer than one month?
- Any infection during your pregnancy?
- None of the above
This field is hidden when viewing the form
34. A)*
- Yes
- No
This field is hidden when viewing the form
34. B)*
- Yes
- No
This field is hidden when viewing the form
34. C)*
- Yes
- No
This field is hidden when viewing the form
34. D)*
- Yes
- No
This field is hidden when viewing the form
34. E)*
- Yes
- No
This field is hidden when viewing the form
34. F)*
- Yes
- No
This field is hidden when viewing the form
34. G)*
- Yes
- No
This field is hidden when viewing the form
34. H)*
- Yes
- No
This field is hidden when viewing the form
34. I)*
- Yes
- No
35. Have you ever tested positive for HTLV-Human T-cell Lymphotrophic Virus (including screening tests) or had unexplained paraparesis (partial paralysis affecting the lower limbs)?*
- Yes
- No
36. Do you understand that if you have the AIDS virus, you can give it to someone else even though you may feel well and have a negative AIDS test?*
- Yes
- No

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Travel Outside the United States
Please read carefully and answer each of the following questions individually.
37. Since 1980, have you ever lived in or travelled to Europe?*
- Yes
- No
Place a check in all the appropriate box(es) to identify the country(ies), reason, date(s) and total time that apply*
- Albania
- Austria
- Belgium
- Bosnia-Herzegovina
- Bulgaria
- Croatia
- Czech Republic
- Denmark
- Finland
- France
- Germany
- Greece
- Hungary
- Ireland (Republic Of)
- Italy
- Kosovo, Montenegro, Serbia
- Liechtenstein
- Luxembourg
- Macedonia
- Netherlands (Holland)
- Norway
- Poland
- Portugal
- Romania
- Slovak Republic
- Slovenia
- Spain
- Sweden
- Switzerland
- Turkey
- United Kingdom (Uk)
- Yugoslavia (Federal Repbulic Of)
- None of the Above
This field is hidden when viewing the form
38. Details*
- Yes
- No
This field is hidden when viewing the form
39. Details*
- Yes
- No
This field is hidden when viewing the form
40. Details*
- Yes
- No
ALBANIA*
- Travel
- Resident
Date(s)*
Total Time*
TURKEY*
- Travel
- Resident
Date(s)*
Total Time*
GREECE*
- Travel
- Resident
Date(s)*
Total Time*
ROMANIA*
- Travel
- Resident
Date(s)*
Total Time*
AUSTRIA*
- Travel
- Resident
Date(s)*
Total Time*
HUNGARY*
- Travel
- Resident
Date(s)*
Total Time*
SLOVAK REPUBLIC*
- Travel
- Resident
Date(s)*
Total Time*
BELGIUM*
- Travel
- Resident
Date(s)*
Total Time*
IRELAND (REPUBLIC OF)*
- Travel
- Resident
Date(s)*
Total Time*
SLOVENIA*
- Travel
- Resident
Date(s)*
Total Time*
BOSNIA-HERZEGOVINA*
- Travel
- Resident
Date(s)*
Total Time*
ITALY*
- Travel
- Resident
Date(s)*
Total Time*
SPAIN*
- Travel
- Resident
Date(s)*
Total Time*
BULGARIA*
- Travel
- Resident
Date(s)*
Total Time*
LIECHTENSTEIN*
- Travel
- Resident
Date(s)*
Total Time*
SWEDEN*
- Travel
- Resident
Date(s)*
Total Time*
CROATIA*
- Travel
- Resident
Date(s)*
Total Time*
LUXEMBOURG*
- Travel
- Resident
Date(s)*
Total Time*
SWITZERLAND*
- Travel
- Resident
Date(s)*
Total Time*
CZECH REPUBLIC*
- Travel
- Resident
Date(s)*
Total Time*
MACEDONIA*
- Travel
- Resident
Date(s)*
Total Time*
UNITED KINGDOM (UK)*
Includes England, Northern Ireland, Scotland, Wales, Isle of Man, Channel Islands Gibraltar & Falkland Islands
- Travel
- Resident
Date(s)*
Total Time*
DENMARK*
- Travel
- Resident
Date(s)*
Total Time*
NETHERLANDS (HOLLAND)*
- Travel
- Resident
Date(s)*
Total Time*
FINLAND*
- Travel
- Resident
Date(s)*
Total Time*
NORWAY*
- Travel
- Resident
Date(s)*
Total Time*
YUGOSLAVIA (FEDERAL REPBULIC OF)*
- Travel
- Resident
Date(s)*
Total Time*
FRANCE*
- Travel
- Resident
Date(s)*
Total Time*
POLAND*
- Travel
- Resident
Date(s)*
Total Time*
KOSOVO, MONTENEGRO, SERBIA*
- Travel
- Resident
Date(s)*
Total Time*
GERMANY*
- Travel
- Resident
Date(s)*
Total Time*
PORTUGAL*
- Travel
- Resident
Date(s)*
Total Time*
38. From 1980 through 1996, did you spend time that adds up to 3 months or more in the United Kingdom?*
Includes England, Northern Ireland, Scotland, Wales, Isle of Man, Channel Islands Gibraltar & Falkland Islands
- Yes
- No
39. Since 1980, have you received a transfusion of blood or blood components while in the UK or France?*
- Yes
- No
40.Since 1980, have you spent time that adds up to 5 years or more in Europe, including time spent in the UK between 1980 and 1996?*
- Yes
- No
41. From 1980 through 1996, were you a member of the U.S. military, a civilian military employee, or a dependent of a member of the U.S. military?*
- Yes
- No
This field is hidden when viewing the form
41. Details
- Yes
- No
This field is hidden when viewing the form
42. Details*
- Yes
- No
This field is hidden when viewing the form
43. Details*
- Yes
- No
42. From 1980 through 1990, did you spend a total of 6 months or more associated with a military base in any of the following countries: United Kingdom, Belgium, Netherlands or Germany?*
- Yes
- No
43. From 1980 through 1996, did you spend a total of 6 months or more associated with a military base in any of the following countries: Spain, Portugal, Turkey, Italy or Greece?*
- Yes
- No

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Travel Outside the United States
Please read carefully and answer each of the following questions individually.
44. Since 1977, were you born in, have you lived in, or have you traveled to any of the following African countries?*
- Benin
- Cameroon
- Central African Republic
- Chad
- Congo
- Equatorial Guinea
- Gabon
- Kenya
- Niger
- Nigeria
- Senegal
- Togo
- Zambia
- None of the Above
BENIN*
- Travel
- Resident
Date(s)*
Total Time*
EQUATORIAL GUINEA*
- Travel
- Resident
Date(s)*
Total Time*
SENEGAL*
- Travel
- Resident
Date(s)*
Total Time*
CAMEROON*
- Travel
- Resident
Date(s)*
Total Time*
GABON*
- Travel
- Resident
Date(s)*
Total Time*
TOGO*
- Travel
- Resident
Date(s)*
Total Time*
CENTRAL AFRICAN REPUBLIC*
- Travel
- Resident
Date(s)*
Total Time*
KENYA*
- Travel
- Resident
Date(s)*
Total Time*
ZAMBIA*
- Travel
- Resident
Date(s)*
Total Time*
CHAD*
- Travel
- Resident
Date(s)*
Total Time*
NIGER*
- Travel
- Resident
Date(s)*
Total Time*
CONGO*
- Travel
- Resident
Date(s)*
Total Time*
NIGERIA*
- Travel
- Resident
Date(s)*
Total Time*
This field is hidden when viewing the form
44. Details
- Yes
- No
This field is hidden when viewing the form
44. New Details*
- Yes
- No
45. While there, did you receive a blood transfusion or any other medical treatment with a product made from blood?*
- Yes
- No
46. Have you had sexual contact with anyone who was born in or lived in any African country listed above since 1977?*
- Yes
- No

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Parent's Information
Please read carefully and answer each of the following questions individually.
47. Were you and/or the baby’s father adopted at early childhood?*
- Yes
- No
Is a family medical history available for you and/or the baby’s father?*
- Yes
- No
48. Are you and the baby’s father related, except by marriage? (e.g. first cousins)*
- Yes
- No
49. Did this pregnancy use either a donor egg or donor sperm?*
- Yes
- No
Is a family medical history questionnaire available for the egg or sperm donor? (please attach copy)*
- Yes
- No
Name of the Clinic*
50. Have you ever had an abnormal result from a prenatal test (e.g. amniocentesis, blood test, and ultrasound)?*
- Yes
- No
Which test was abnormal?*
What was the abnormal test result*
Was a diagnosis made? Specify diagnosis*
51. Have you had any children who died within the first 10 years of life?*
- Yes
- No
What was the cause?*
52. Have you ever had a stillborn child?*
- Yes
- No
What was the cause?*
53. Have you had a medical diagnosis of ZIKV (Zika) infection at any point during your pregnancy?*
- Yes
- No
54. Have you resided in, or travel to, an area with active ZIKV (Zika) transmission at any point during your pregnancy?*
- Yes
- No
55. Have you had sex during your pregnancy with a male or female who is known to have:*
a) A medical diagnosis of ZIKV (Zika) within the six months prior to that contact b) Resided in, or traveled to, an area with active ZIKV (Zika) transmission within the six months prior to that contact.
- Yes
- No

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Family Medical History
For the following questions please describe the relationship between the baby and all family members with each disease. Note parents’ sibling refer to the baby’s aunts and uncles by blood, and does not include aunts and uncles who are in-laws of the parents.
56. Cancer or Leukemia?*
Please answer for IMMEDIATE FAMILY ONLY (mother, father, siblings)
- Brain or other nervous system cancer
- Bone or joint cancer
- Kidney (including renal pelvic) cancer
- Thyroid Cancer
- Hodgkin’s Lymphoma
- Non-Hodgkin’s Lymphoma
- Acute or chronic myelogenous/myeloid leukemia
- Acute or chronic lymphocytic/lymphoblastic leukemia
- Skin Cancer
- Other cancer/leukemia
- None of the Above
This field is hidden when viewing the form
56. Details
- Yes
- No
Please provide details on which family member(s):
Brain or other nervous system cancer*
Check all that apply
- Baby’s Mother
- Baby’s Father
- Baby’s sibling
Bone or joint cancer*
Check all that apply
- Baby’s Mother
- Baby’s Father
- Baby’s sibling
Kidney (including renal pelvic) cancer*
Check all that apply
- Baby’s Mother
- Baby’s Father
- Baby’s sibling
Thyroid Cancer*
Check all that apply
- Baby’s Mother
- Baby’s Father
- Baby’s sibling
Hodgkin’s Lymphoma*
Check all that apply
- Baby’s Mother
- Baby’s Father
- Baby’s sibling
Non-Hodgkin’s Lymphoma*
Check all that apply
- Baby’s Mother
- Baby’s Father
- Baby’s sibling
Acute or chronic myelogenous/myeloid leukemia*
Check all that apply
- Baby’s Mother
- Baby’s Father
- Baby’s sibling
Acute or chronic lymphocytic/lymphoblastic leukemia*
Check all that apply
- Baby’s Mother
- Baby’s Father
- Baby’s sibling
Skin Cancer*
Check all that apply
- Baby’s Mother
- Baby’s Father
- Baby’s sibling
Other cancer/leukemia*
Check all that apply
- Baby’s Mother
- Baby’s Father
- Baby’s sibling
Specify Type*
Specify Type*
57. Red Blood Cell Disease?*
Please answer for EXTENDED FAMILY (baby’s mother, father, siblings, aunts, uncles, grandparents)
- Diamond-Blackfan Syndrome
- Elliptocytosis
- G6PD or other red cell enzyme deficiency
- Spherocytosis
- None of the Above
This field is hidden when viewing the form
57. Details
- Yes
- No
Please provide details on which family member(s):
Diamond-Blackfan Syndrome*
Please select all that apply
- Baby’s Mother
- Baby’s Father
- Baby’s sibling
- Baby’s Grandparent
- Baby’s Mother Sibling
- Baby’s Father’s Sibling
Elliptocytosis*
Please select all that apply
- Baby’s Mother
- Baby’s Father
- Baby’s sibling
- Baby’s Grandparent
- Baby’s Mother Sibling
- Baby’s Father’s Sibling
G6PD or other red cell enzyme deficiency*
Please select all that apply
- Baby’s Mother
- Baby’s Father
- Baby’s sibling
- Baby’s Grandparent
- Baby’s Mother Sibling
- Baby’s Father’s Sibling
Spherocytosis*
Please select all that apply
- Baby’s Mother
- Baby’s Father
- Baby’s sibling
- Baby’s Grandparent
- Baby’s Mother Sibling
- Baby’s Father’s Sibling
58. White Blood Cell Disease?*
Please answer for EXTENDED FAMILY (baby’s mother, father, siblings, aunts, uncles, grandparents)
- Chronic Granulomatous Disease
- Kostmann Syndrome
- Schwachman-Diamond Syndrome
- Leukocyte Adhesion Deficiency (LAD)
- None of the Above
This field is hidden when viewing the form
59. Details
- Yes
- No
Please provide details on which family member(s):
Chronic Granulomatous Disease*
Select all that apply.
- Baby’s Mother
- Baby’s Father
- Baby’s sibling
- Baby’s Grandparent
- Baby’s Mother Sibling
- Baby’s Father’s Sibling
Kostmann Syndrome*
Select all that apply.
- Baby’s Mother
- Baby’s Father
- Baby’s sibling
- Baby’s Grandparent
- Baby’s Mother Sibling
- Baby’s Father’s Sibling
Schwachman-Diamond Syndrome*
Select all that apply.
- Baby’s Mother
- Baby’s Father
- Baby’s sibling
- Baby’s Grandparent
- Baby’s Mother Sibling
- Baby’s Father’s Sibling
Leukocyte Adhesion Deficiency (LAD)*
Select all that apply.
- Baby’s Mother
- Baby’s Father
- Baby’s sibling
- Baby’s Grandparent
- Baby’s Mother Sibling
- Baby’s Father’s Sibling
59. Immune Deficiencies?*
Please answer for EXTENDED FAMILY (baby’s mother, father, siblings, aunts, uncles, grandparents)
- ADA or PNP Deficiency
- Combined Immunodeficiency Syndrome (CID), Common Variable Immunodeficiency Disease (CVID)
- DiGeorge Syndrome
- Hereditary Hemophagocytic Lymphohistiocytosis (HLH) including FEL
- Hypoglobulinemia
- Nezeloff Syndrome
- Severe Combined Immunodeficiency
- Wiskott-Aldrich Syndrome
- None of the Above
This field is hidden when viewing the form
59. Details
- Yes
- No
Please provide details on which family member(s):
ADA or PNP Deficiency*
Please select all that apply.
- Baby’s Mother
- Baby’s Father
- Baby’s sibling
- Baby’s Grandparent
- Baby’s Mother Sibling
- Baby’s Father’s Sibling
Combined Immunodeficiency Syndrome (CID), Common Variable Immunodeficiency Disease (CVID)*
Please select all that apply.
- Baby’s Mother
- Baby’s Father
- Baby’s sibling
- Baby’s Grandparent
- Baby’s Mother Sibling
- Baby’s Father’s Sibling
DiGeorge Syndrome*
Please select all that apply.
- Baby’s Mother
- Baby’s Father
- Baby’s sibling
- Baby’s Grandparent
- Baby’s Mother Sibling
- Baby’s Father’s Sibling
Hereditary Hemophagocytic Lymphohistiocytosis (HLH) including FEL*
Please select all that apply.
- Baby’s Mother
- Baby’s Father
- Baby’s sibling
- Baby’s Grandparent
- Baby’s Mother Sibling
- Baby’s Father’s Sibling
Hypoglobulinemia*
Please select all that apply.
- Baby’s Mother
- Baby’s Father
- Baby’s sibling
- Baby’s Grandparent
- Baby’s Mother Sibling
- Baby’s Father’s Sibling
Nezeloff Syndrome*
Please select all that apply.
- Baby’s Mother
- Baby’s Father
- Baby’s sibling
- Baby’s Grandparent
- Baby’s Mother Sibling
- Baby’s Father’s Sibling
Severe Combined Immunodeficiency*
Please select all that apply.
- Baby’s Mother
- Baby’s Father
- Baby’s sibling
- Baby’s Grandparent
- Baby’s Mother Sibling
- Baby’s Father’s Sibling
Wiskott-Aldrich Syndrome*
Please select all that apply.
- Baby’s Mother
- Baby’s Father
- Baby’s sibling
- Baby’s Grandparent
- Baby’s Mother Sibling
- Baby’s Father’s Sibling
60. Platelet Disease?*
Please answer for EXTENDED FAMILY (baby’s mother, father, siblings, aunts, uncles, grandparents)
- Amegakaryocytic Thrombocytopenia
- Glanzmann Thrombasthenia
- Hereditary Thrombocytopenia
- Platelet Storage Pool Disease
- Thrombocytopenia with absent radii (TAR)
- Ataxia-Telangiectasia
- Fanconi Anemia
- None of the Above
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60. Details
- Yes
- No
Please provide details on which family member(s):
Amegakaryocytic Thrombocytopenia*
Please specify all that apply.
- Baby’s Mother
- Baby’s Father
- Baby’s sibling
- Baby’s Grandparent
- Baby’s Mother Sibling
- Baby’s Father’s Sibling
Glanzmann Thrombasthenia*
Please specify all that apply.
- Baby’s Mother
- Baby’s Father
- Baby’s sibling
- Baby’s Grandparent
- Baby’s Mother Sibling
- Baby’s Father’s Sibling
Hereditary Thrombocytopenia*
Please specify all that apply.
- Baby’s Mother
- Baby’s Father
- Baby’s sibling
- Baby’s Grandparent
- Baby’s Mother Sibling
- Baby’s Father’s Sibling
Platelet Storage Pool Disease*
Please specify all that apply.
- Baby’s Mother
- Baby’s Father
- Baby’s sibling
- Baby’s Grandparent
- Baby’s Mother Sibling
- Baby’s Father’s Sibling
Thrombocytopenia with absent radii (TAR)*
Please specify all that apply.
- Baby’s Mother
- Baby’s Father
- Baby’s sibling
- Baby’s Grandparent
- Baby’s Mother Sibling
- Baby’s Father’s Sibling
Ataxia-Telangiectasia*
Please specify all that apply.
- Baby’s Mother
- Baby’s Father
- Baby’s sibling
- Baby’s Grandparent
- Baby’s Mother Sibling
- Baby’s Father’s Sibling
Fanconi Anemia*
Please specify all that apply.
- Baby’s Mother
- Baby’s Father
- Baby’s sibling
- Baby’s Grandparent
- Baby’s Mother Sibling
- Baby’s Father’s Sibling
61. Other blood disorder or problem?*
Please answer for EXTENDED FAMILY (baby’s mother, father, siblings, aunts, uncles, grandparents)
- Yes
- No
61.1*
Specify relative(s) with other blood disorder or problem. Please specify all that apply.
- Baby’s Mother
- Baby’s Father
- Baby’s Sibling
- Baby’s Grandparent
- Baby’s Mother Sibling
- Baby’s Father’s Sibling
Specify what blood disorder(s)*
62. Sickle cell disease, such as sickle-cell anemia or sickle thalassemia?*
Please answer for EXTENDED FAMILY (baby’s mother, father, siblings, aunts, uncles, grandparents)
- Yes
- No
Specify which sickle cell disease*
62.1*
Specify which family members (check all that apply).
- Baby’s Mother
- Baby’s Father
- Baby’s sibling
- Baby’s Grandparent
- Baby’s Mother Sibling
- Baby’s Father’s Sibling
63. Thalassemia, such as alpha thalassemia or beta-thalassemia?*
Please answer for EXTENDED FAMILY (baby’s mother, father, siblings, aunts, uncles, grandparents)
- Yes
- No
63.1*
Specify which family members (check all that apply).
- Baby’s Mother
- Baby’s Father
- Baby’s sibling
- Baby’s Grandparent
- Baby’s Mother Sibling
- Baby’s Father’s Sibling
64. Metabolic/Storage Disease?*
Please answer for EXTENDED FAMILY (baby’s mother, father, siblings, aunts, uncles, grandparents)
- Hurler Syndrome (MPS I)
- Hurler-Scheie Syndrome (MPS I H-S)
- Hunter Syndrome (MPS II)
- Sanfilippo Syndrome (MPS III)
- Morquio Syndrome (MPS IV)
- Maroteaux-Lamy Syndrome (MPS VI)
- Sly Syndrome (MPS VII)
- I-cell disease
- Globoid Leukodystrophy (Krabbe Disease)
- Metachromatic Leukodystrophy (MLD)
- Adrenoleukodystrophy (ALD)
- Sandhoff Disease
- Tay-Sachs Disease
- Gaucher Disease
- Niemann Pick-Disease
- Porphyria
- Other or unknown metabolic/storage disease
- None of the Above
This field is hidden when viewing the form
64. Details
- Yes
- No
Please provide details on which family member(s):
Hurler Syndrome (MPS I)*
Specify which family members (check all that apply).
- Baby’s Mother
- Baby’s Father
- Baby’s sibling
- Baby’s Grandparent
- Baby’s Mother Sibling
- Baby’s Father’s Sibling
Hurler-Scheie Syndrome (MPS I H-S)*
Specify which family members (check all that apply).
- Baby’s Mother
- Baby’s Father
- Baby’s sibling
- Baby’s Grandparent
- Baby’s Mother Sibling
- Baby’s Father’s Sibling
Hunter Syndrome (MPS II)*
Specify which family members (check all that apply).
- Baby’s Mother
- Baby’s Father
- Baby’s sibling
- Baby’s Grandparent
- Baby’s Mother Sibling
- Baby’s Father’s Sibling
Sanfilippo Syndrome (MPS III)*
Specify which family members (check all that apply).
- Baby’s Mother
- Baby’s Father
- Baby’s sibling
- Baby’s Grandparent
- Baby’s Mother Sibling
- Baby’s Father’s Sibling
Morquio Syndrome (MPS IV)*
Specify which family members (check all that apply).
- Baby’s Mother
- Baby’s Father
- Baby’s sibling
- Baby’s Grandparent
- Baby’s Mother Sibling
- Baby’s Father’s Sibling
Maroteaux-Lamy Syndrome (MPS VI)*
Specify which family members (check all that apply).
- Baby’s Mother
- Baby’s Father
- Baby’s sibling
- Baby’s Grandparent
- Baby’s Mother Sibling
- Baby’s Father’s Sibling
Sly Syndrome (MPS VII)*
Specify which family members (check all that apply).
- Baby’s Mother
- Baby’s Father
- Baby’s sibling
- Baby’s Grandparent
- Baby’s Mother Sibling
- Baby’s Father’s Sibling
I-cell disease*
Specify which family members (check all that apply).
- Baby’s Mother
- Baby’s Father
- Baby’s sibling
- Baby’s Grandparent
- Baby’s Mother Sibling
- Baby’s Father’s Sibling
Globoid Leukodystrophy (Krabbe Disease)*
Specify which family members (check all that apply).
- Baby’s Mother
- Baby’s Father
- Baby’s sibling
- Baby’s Grandparent
- Baby’s Mother Sibling
- Baby’s Father’s Sibling
Metachromatic Leukodystrophy (MLD)*
Specify which family members (check all that apply).
- Baby’s Mother
- Baby’s Father
- Baby’s sibling
- Baby’s Grandparent
- Baby’s Mother Sibling
- Baby’s Father’s Sibling
Adrenoleukodystrophy (ALD)*
Specify which family members (check all that apply).
- Baby’s Mother
- Baby’s Father
- Baby’s sibling
- Baby’s Grandparent
- Baby’s Mother Sibling
- Baby’s Father’s Sibling
Sandhoff Disease*
Specify which family members (check all that apply).
- Baby’s Mother
- Baby’s Father
- Baby’s sibling
- Baby’s Grandparent
- Baby’s Mother Sibling
- Baby’s Father’s Sibling
Tay-Sachs Disease*
Specify which family members (check all that apply).
- Baby’s Mother
- Baby’s Father
- Baby’s sibling
- Baby’s Grandparent
- Baby’s Mother Sibling
- Baby’s Father’s Sibling
Gaucher Disease*
Specify which family members (check all that apply).
- Baby’s Mother
- Baby’s Father
- Baby’s sibling
- Baby’s Grandparent
- Baby’s Mother Sibling
- Baby’s Father’s Sibling
Niemann Pick-Disease*
Specify which family members (check all that apply).
- Baby’s Mother
- Baby’s Father
- Baby’s sibling
- Baby’s Grandparent
- Baby’s Mother Sibling
- Baby’s Father’s Sibling
Porphyria*
Specify which family members (check all that apply).
- Baby’s Mother
- Baby’s Father
- Baby’s sibling
- Baby’s Grandparent
- Baby’s Mother Sibling
- Baby’s Father’s Sibling
64.Q Other*
Specify which family members (check all that apply).
- Baby’s Mother
- Baby’s Father
- Baby’s sibling
- Baby’s Grandparent
- Baby’s Mother Sibling
- Baby’s Father’s Sibling
64. Q Other Details*
65. HIV/AIDS?*
Please answer for IMMEDIATE FAMILY ONLY (mother, father, siblings)
- Yes
- No
65.1*
Please specify which family members.
- Baby’s Mother
- Baby’s Father
- Baby’s sibling
66. Severe Autoimmune Disorder?*
Please answer for IMMEDIATE FAMILY ONLY (mother, father, siblings).
- Crohn’s Disease or Ulcerative Colitis
- Lupus
- Multiple Sclerosis (MS)
- Rheumatoid Arthritis
- None of the Above
This field is hidden when viewing the form
66. Details
- Yes
- No
Please specify which family members and provide the other requested information.
Crohn’s Disease or Ulcerative Colitis*
Please select which family members.
- Baby’s Mother
- Baby’s Father
- Baby’s sibling
Lupus*
Please select which family members.
- Baby’s Mother
- Baby’s Father
- Baby’s sibling
Multiple Sclerosis (MS)*
Please select which family members.
- Baby’s Mother
- Baby’s Father
- Baby’s sibling
Rheumatoid Arthritis*
Please select which family members.
- Baby’s Mother
- Baby’s Father
- Baby’s sibling
Diagnosis Date*
MM slash DD slash YYYY
Currently under MD care? Describe*
Currently taking any medication? Name*
This field is hidden when viewing the form
66. Yes Sibling
- Yes
This field is hidden when viewing the form
66. Yes Mother
- Yes
This field is hidden when viewing the form
66. Yes Father
- Yes
67. Any diagnosis of other or unknown immune system disorder?*
Please answer for IMMEDIATE FAMILY ONLY (mother, father, siblings)
- Yes
- No
67.1*
Please specify which family members.
- Baby’s Mother
- Baby’s Father
- Baby’s sibling
Specify Disorder*
68. Required Chronic Blood Transfusions?*
Please answer for EXTENDED FAMILY (baby’s mother, father, siblings, aunts, uncles, grandparents)
- Yes
- No
68.1*
Please specify which family members.
- Baby’s Mother
- Baby’s Father
- Baby’s sibling
- Baby’s Grandparent
- Baby’s Mother Sibling
- Baby’s Father’s Sibling
69. Been told you or your family member(s) have hemolytic anemia?*
Please answer for EXTENDED FAMILY (baby’s mother, father, siblings, aunts, uncles, grandparents)
- Yes
- No
69.1*
Please specify which family members.
- Baby’s Mother
- Baby’s Father
- Baby’s sibling
- Baby’s Grandparent
- Baby’s Mother Sibling
- Baby’s Father’s Sibling
70. Had spleen removed to treat a blood disorder?*
Please answer for EXTENDED FAMILY (baby’s mother, father, siblings, aunts, uncles, grandparents)
- Yes
- No
70.1*
Please specify all that apply.
- Baby’s Mother
- Baby’s Father
- Baby’s sibling
- Baby’s Grandparent
- Baby’s Mother Sibling
- Baby’s Father’s Sibling
71. Had gallbladder removed before the age of 30?*
Please answer for EXTENDED FAMILY (baby’s mother, father, siblings, aunts, uncles, grandparents)
- Yes
- No
71.1*
Please specify all that apply.
- Baby’s Mother
- Baby’s Father
- Baby’s sibling
- Baby’s Grandparent
- Baby’s Mother Sibling
- Baby’s Father’s Sibling
72. Had Creutzfeldt-Jakob disease (CJD)?*
Please answer for EXTENDED FAMILY (baby’s mother, father, siblings, aunts, uncles, grandparents)
- Yes
- No
72.1*
Please specify all that apply.
- Baby’s Mother
- Baby’s Father
- Baby’s sibling
- Baby’s Grandparent
- Baby’s Mother Sibling
- Baby’s Father’s Sibling
73. Other serious or life-threatening diseases affecting the family?*
Please answer for EXTENDED FAMILY (baby’s mother, father, siblings, aunts, uncles, grandparents)
- Yes
- No
Please list type of disease and affected family member(s)
No of Diseases*
- Disease 1
- Disease 2
- Disease 3
73.1. Specify Type of Disease*
73.1 Details*
Please specify all that apply.
- Baby’s Mother
- Baby’s Father
- Baby’s sibling
- Baby’s Grandparent
- Baby’s Mother Sibling
- Baby’s Father’s Sibling
73.2. Specify Type of Disease
73.2 Details*
Please specify all that apply.
- Baby’s Mother
- Baby’s Father
- Baby’s sibling
- Baby’s Grandparent
- Baby’s Mother Sibling
- Baby’s Father’s Sibling
73.3 Specify Type of Disease
73.3 Details*
Please specify all that apply.
- Baby’s Mother
- Baby’s Father
- Baby’s sibling
- Baby’s Grandparent
- Baby’s Mother Sibling
- Baby’s Father’s Sibling
74. In answering these questions, have you answered for both your family and the baby’s father’s family?*
- Yes
- No

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Addendum A:
1. Any history of acute respiratory disease?*
- Yes
- No
Please describe*
2. Any active tuberculosis disease or history of tuberculosis therapy?*
- Yes
- No
Please describe*
3. Any history of drug or alcohol abuse?*
- Yes
- No
Please describe*
Addendum B: COVID-19 or Severe Acute Respiratory Syndrome (SARS)
1. Have you received a COVID-19 vaccination*
- Yes
- No

Save and Continue Later

Δ

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Deborah A. Sardone

Ms. Sardone has over 30 years of clinical laboratory experience as a Clinical Laboratory Technologist and Supervisor, including over 25 years with Central Florida Regional Hospital (CFRH). She was Supervisor of Quality Assurance, Safety and Education at CFRH for 11 years, held the positions of Blood Bank Supervisor for 11 years, and Hematology Supervisor for 1 year. She has participated in both sides of the inspection process, serving on the College of American Pathologists Inspection team for CAP Hospital Accreditation in Florida, and assisting in receiving accreditation by The Joint Commission (TJC), American Association of Blood Banks (AABB), and Food and Drug Administration (FDA) through the inspections of the clinical laboratory. Ms. Sardone is licensed by the State of Florida as a Clinical Laboratory Technologist in Immunohematology, Hematology, Serology and Clinical Chemistry. She is a certified Clinical Laboratory Technologist with the American Society of Clinical Pathologists (ASCP). Ms. Sardone serves as Manager of Quality Assurance and Regulatory Affairs at Cord For Life, Inc. overseeing all licensing and regulatory agencies to ensure that the highest quality in all aspects of cord blood collection, processing, and storage is maintained. Ms. Sardone has been with Cord For Life for over 5 years of dedicated service. Her skills and knowledge in blood banking and quality assurance have enabled her to establish, implement and maintain a superior quality system that meets and exceeds all standards and regulatory requirements for Cord For Life, Inc.

Personal Background:

Sardone is a graduate of The City University of New York in Medical Laboratory Technology.
Sardone is licensed in Florida as a Clinical Medical Technologist and she is nationally recognized as ASCP Certified.
Sardone enjoys photography and dancing.

Kelli Cable

Ms. Cable has 35+ years – experience in Office, Management, Human Resources, & Customer Service. As the Director of Administration and Client Services, Ms. Cable joined Cord for Life in December 2006, and has assisted in providing more efficient and effective ways to ease the enrollment process, as well as obtaining and establishing excellent customer care during the enrollment and donation period; for our Storage and Donation customers.

Personal Background:

Mrs. Cable is married and has two boys.
In 1994, Ms. Cable moved to Orlando from Boulder, Colorado.
Has a passion for travel and enjoys watching NFL games, cheering on her favorite team, the Denver Broncos.

Donald Hudspeth

Mr. Hudspeth has over 28 years of clinical laboratory experience as a certified Medical Technologist (ASCP), including ten years with the University of North Carolina Hospitals and 18 years with Cord for Life. Mr. Hudspeth is licensed by the State of Florida as a Clinical Laboratory Supervisor in Immunohematology, Hematology, Serology, Clinical Chemistry, Molecular Pathology and Microbiology as well as a Clinical Laboratory Scientist and has completed the AABB Certification in Cellular Therapies through George Washington University.

Mr. Hudspeth is a registered Technologist with the American Society of Clinical Pathologists and a member of the Cord Blood Association. He has also enjoyed teaching Immunology to Clinical Laboratory Science and medical school students at UNC while working in the UNCH clinical labs. Mr. Hudspeth is an Eagle Scout with 5 palms and has served numerous volunteer positions within the local Scouts BSA Troop and Pack.

Personal Background:

Mr. Hudspeth received his Bachelor’s degree in Clinical Laboratory Sciences from the University of North Carolina at Chapel Hill.
“Eagle Scout with Five Palms”
Avid golfer with a 14 handicap.

Sara Irrgang, M.D

During the last two years of Medical School, Dr. Irrgang was in the United States Navy 1915 Ensign Program and completed a clerkship at the Naval Hospital at Charleston, South Carolina as well as a research clerkship at the Naval Aerospace Institute at Pensacola, Florida. Dr. Irrgang completed her four year Pathology residency at Baylor University Medical Center, and her internship at the University District Hospital, Rio Piedras in San Juan, Puerto Rico.

Currently, Dr. Irrgang is Board Certified in Anatomic and Clinical Pathology and licensed in the states of South Carolina, Texas, New Jersey and Florida and she is an Associate Medical Examiner at the District Nine Medical Examiners Office. Dr. Irrgang is a fellow at numerous organizations including; The College of American Pathologists, National Association of Medical Examiners, Florida Association of Medical Examiners, Seminole County Medical Society, and the Florida Medical Society.

Personal Background:

Dr. Irrgang received a Bachelor of Science degree in Pharmacy from the University of South Carolina.
Attended the Medical College of South Carolina at Charleston where she earned a Medical Doctorate Degree.
Dr. Irrgang has a passion for breeding show horses
Dr. Irrgang is a 4-H leader in Lake County, Florida

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