Personal Behavior History

Question Response
Current alcohol use:
If yes, oz./week and type of alcohol:
Rarely - Beer. 5oz a week
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

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:
Wrist surgery - Age 27, Bicycle accident
Hospitalization other than surgery:
Age & type of illness:
N/A
Have you ever had any broken bones?
If yes, please give age and description:
Yes - Age 27, broke wrist in a bicycle accident
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:Marijuana - Once a month; Sporadically; Recreation
List all current medication or treatments (include vitamins, aspirin, antacids, laxatives, herbal, sports supplements, etc.) Include drug, frequency and duration taken, and reason:Vitamin D - Once a week ; About 3 years; My doctor suggested as a precaution
Do you wear glasses or contact lenses?
Are you near or far-sighted?
Yes - Near-sighted, 20/40
Birth weight lbs8
Birth weight ozs7
Recent weight loss or gain?
# of lbs and reason:
No
Allergies (medicines, food, pollens)?
If yes, please list substance and reaction caused:
Yes - Penicillin, rash
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 History
Ver lista de perguntas. here

Mother's Father Ethnic OriginsItalian
Mother's Mother Ethnic OriginsGerman
Father's Father Ethnic OriginsPolish
Father's Mother Ethnic OriginGerman
Is anyone in your family of Ashkenazai Jewish Heritage?No
If yes, who?N/A
Question Response
Current age or age at death 68
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Problemas de Saúde
Saudável
Question Response
Current age or age at death 69
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Problemas de Saúde
Saudável
Question Response
Current age or age at death 42
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Problemas de Saúde
Saudável
Question Response
Current age or age at death 41
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Problemas de Saúde
Saudável
Question Response
Current age or age at death 4
Living / DeadLiving
Problemas de Saúde
Saudável
Question Response
Current age or age at death 82
Living / DeadDead
Cause of death and any treatment prior to deathComplications from Alzheimer's
Problemas de Saúde
Disease
Age Diagnosed
Treatment For Condition
Alzheimer's
78
Nursing care
Question Response
Current age or age at death 92
Living / DeadDead
Cause of death and any treatment prior to deathHeart Failure
Problemas de Saúde
Disease
Age Diagnosed
Treatment For Condition
Other disease of the kidney, urinary tract, urethra, bladder, ureter
85
Bladder infections treated with antibiotics
Osteoarthritis
50
Physical therapy and medication
Question Response
Current age or age at death 73
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Problemas de Saúde
Saudável
Question Response
Current age or age at death 71
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Problemas de Saúde
Saudável
Question Response
Current age or age at death 65
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Problemas de Saúde
Saudável
Question Response
Current age or age at death 60
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Problemas de Saúde
Saudável
Question Response
Current age or age at death 65
Living / DeadDead
Cause of death and any treatment prior to deathHeart Failure
Problemas de Saúde
Disease
Age Diagnosed
Treatment For Condition
Other
 
Work related joint pain, and frequent bladder infections
Question Response
Current age or age at death 91
Living / DeadDead
Cause of death and any treatment prior to deathComplications from old age
Problemas de Saúde
Disease
Age Diagnosed
Treatment For Condition
Other
 
No known diagnosed health problems at time of death
Question Response
Current age or age at death 68
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Problemas de Saúde
Saudável