This donor is a healthy carrier for a genetic disease.
Please see his Genetic Testing Summary and Acknowledgment of Genetic Risk for details
Please see his Genetic Testing Summary and Acknowledgment of Genetic Risk for details
Personal Behavior History
Question | Response |
Current alcohol use: If yes, oz./week and type of alcohol: | Occasionally - 24-36 oz. beer/month or 12-18 oz. wine/month |
Tobacco use: Do you smoke? If yes, #/day and for how long: | No |
If you did smoke but quit, when did you last smoke? | N/A |
For how many years? | N/A |
Do you sleep well? | Yes |
Do you exercise on regular basis? | Yes |
Is your diet well balanced? If no, explain: | Yes |
Are you a vegetarian? | No |
Any dietary restrictions? If yes, explain: | No |
Sexual History
Have you ever had sex with:
Question | Response |
A partner whose sexual background you are unsure of in the past 12 months? | No |
Donor Genetic History
Question | Response |
Do you have a history of a speech disorder; such as a speech impediment, stuttering, delayed speech development, etc.? If yes, explain: | No |
Do you have learning differences, such as dyslexia? If yes, explain: | No |
Were you or any family members born with any birth defects? If yes, explain: | No |
Donor Medical History
Question | Response |
List any operations: Age & reason: | Tonsillectomy at age 6 due to allergies; Wisdom teeth extraction (4 teeth) at age 16 |
Hospitalization other than surgery: Age & type of illness: | None |
Have you ever had any broken bones? If yes, please give age and description: | Yes - Broken right thumb at age 9, dropped a bowling ball on it |
Have you ever had any serious illnesses? If yes, please give age and description: | No |
Are you presently under a physician's care for any reason? If yes, please describe: | No |
List all drugs you have taken in past 12 months (prescription, nonprescription, herbal, and sports supplements, and recreational). Include drug, frequency and duration taken, and reason: | None - N/A; N/A; N/A |
List all current medication or treatments (include vitamins, aspirin, antacids, laxatives, herbal, sports supplements, etc.) Include drug, frequency and duration taken, and reason: | Multivitamin - Once daily; 6 months; General health |
Do you wear glasses or contact lenses? Are you near or far-sighted? | Yes - 20/40 |
Birth weight lbs | 9 |
Birth weight ozs | 4 |
Recent weight loss or gain? # of lbs and reason: | No |
Allergies (medicines, food, pollens)? If yes, please list substance and reaction caused: | No |
How many sexual partners do you currently have? | 1 |
Have you ever had a tattoo? | No |
Have you ever had your ear(s) or body pierced? | No |
Family Medical HistoryVer lista de perguntas. here
Mother's Father Ethnic Origins | German-Irish |
Mother's Mother Ethnic Origins | Irish |
Father's Father Ethnic Origins | German-Polish |
Father's Mother Ethnic Origin | Polish |
Is anyone in your family of Ashkenazai Jewish Heritage? | No |
If yes, who? | N/A |
Your Mother
Question | Response |
Current age or age at death | 62 |
Living / Dead | Living |
Cause of death and any treatment prior to death | N/A |
Problemas de Saúde
Disease
Age Diagnosed
Treatment For Condition
Hay fever/Seasonal Allergies/Allergic Rhinitis
30
No treatment
Your Father
Question | Response |
Current age or age at death | 63 |
Living / Dead | Living |
Cause of death and any treatment prior to death | N/A |
Problemas de Saúde
Disease
Age Diagnosed
Treatment For Condition
Depression
25
Situational, cognitive behavioral therapy previously, no longer needs treatment
Brothers
Your Brother 1
Question | Response |
Current age or age at death | 30 |
Living / Dead | Dead |
Cause of death and any treatment prior to death | Drowned |
Problemas de Saúde
Disease
Age Diagnosed
Treatment For Condition
Other
No diagnosed health problems prior to death
Your Brother 2
Question | Response |
Current age or age at death | 26 |
Living / Dead | Living |
Cause of death and any treatment prior to death | N/A |
Problemas de Saúde
Saudável
Your Mother's Father
Question | Response |
Current age or age at death | 85 |
Living / Dead | Dead |
Cause of death and any treatment prior to death | Prostate cancer |
Problemas de Saúde
Disease
Age Diagnosed
Treatment For Condition
Prostate cancer
85
Fatal, diagnosed late stage
Your Mother's Mother
Question | Response |
Current age or age at death | 76 |
Living / Dead | Dead |
Cause of death and any treatment prior to death | Cirrhosis of the liver |
Problemas de Saúde
Disease
Age Diagnosed
Treatment For Condition
Other liver disease
76
Diagnosed at death, Cirrhosis of liver cause by regular drinking, confirmed no alcohol addiction
Your Mother's Sisters 1
Question | Response |
Current age or age at death | 81 |
Living / Dead | Living |
Cause of death and any treatment prior to death | N/A |
Problemas de Saúde
Saudável
Your Mother's Sisters 2
Question | Response |
Current age or age at death | 75 |
Living / Dead | Living |
Cause of death and any treatment prior to death | N/A |
Problemas de Saúde
Saudável
Your Mother's Sisters 3
Question | Response |
Current age or age at death | 71 |
Living / Dead | Living |
Cause of death and any treatment prior to death | N/A |
Problemas de Saúde
Disease
Age Diagnosed
Treatment For Condition
High blood pressure
50
Diet changes, Stopped smoking
Your Mother's Brothers 1
Question | Response |
Current age or age at death | 78 |
Living / Dead | Living |
Cause of death and any treatment prior to death | N/A |
Problemas de Saúde
Disease
Age Diagnosed
Treatment For Condition
Drug abuse, misuse, or addiction
40
Alcoholics Anonymous (recovering alcoholic); does not drink anymore
Your Father's Father
Question | Response |
Current age or age at death | 50 |
Living / Dead | Dead |
Cause of death and any treatment prior to death | Heart attack |
Problemas de Saúde
Disease
Age Diagnosed
Treatment For Condition
Heart attack
50
Fatal, no treatment
Your Father's Mother
Question | Response |
Current age or age at death | 86 |
Living / Dead | Living |
Cause of death and any treatment prior to death | N/A |
Problemas de Saúde
Saudável
Your Father's Sisters 1
Question | Response |
Current age or age at death | 65 |
Living / Dead | Living |
Cause of death and any treatment prior to death | N/A |
Problemas de Saúde
Saudável
Your Father's Sisters 2
Question | Response |
Current age or age at death | 58 |
Living / Dead | Living |
Cause of death and any treatment prior to death | N/A |
Problemas de Saúde
Saudável