Yes No
1. Will your new born be of non-Caucasian ethnicity or of mixed heritage such as the parents or grandparents being from different parts of the world?

Yes No
2. Does your family have a history of blood related diseases, such as: Aplastic Anemia, Fanconi’s Anemia, or a history of Leukemia?

True False
3. The chance of my child needing a stem cell transplant is not very likely.

Yes No
4. Does your family have a history of Sickle Cell Disease or Thalassemia?

Yes No
5. Was the new born you are expecting conceived using either anonymous donor sperm or an anonymous donor egg?