11 



Culture Medium in which Submitted: 



13. Special Instruct ion(s ) on Handling or Freezing of Culture/Biopsy? 

 Q] No [2j Yes 



( Specify) 



14. Have Chromosome Studies ever been Done on this Individual? 



|T| Information Not Available (Go to Item 22) 



[2] No (Go to Item 22) 



[T| No, but Studies are Underway (Go to Item 22) 



[4] Yes 



[T] On Cells from this Culture 



[2] On Cells from Other Tissue/Samples 



15. General Karyotype Results: \T\ Normal 



[2] Abnormal 



\T\ Balanced 

 [2j Unbalanced 

 [3J Not Certain 



16. Sex Chromosomal Complement: (Check One or More) 



LH XX [2] XO [3j XXX 



[4] XY [3J XXY [H XYY [7] XXXY 



[8j Other 



( Specify) 



17. Aut osomal Mosaicism? 



[T] Detected (If so, # and % Sub Lines: 



w 



H 



to 



o 

 § 



CO 



§ 



a 



Not Detected 

 Suspected 



19 



