Personal Behavior History
Donor Sexual History
Donor Genetic History
Donor Medical History
Family Medical HistoryThis 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 - 12 oz. White claw seltzer |
| 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: | Laser eye surgery - Age 18, to correct near-sightedness |
| Hospitalization other than surgery: Age & type of illness: | N/A - N/A |
| Have you ever had any broken bones? If yes, please give age and description: | Yes - Broken pinkie finger during basketball, 14 years old |
| 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: | Ibuprofen, Tylenol, Maxalt - 2-3 times a week; 12 months ; Avoid pain from sports |
| List all current medication or treatments (include vitamins, aspirin, antacids, laxatives, herbal, sports supplements, etc.) Include drug, frequency and duration taken, and reason: | Ibuprofen, Maxalt - 2-3 times a week; 12 months ; Avoid pain from sports |
| Do you wear glasses or contact lenses? Are you near or far-sighted? | No |
| Birth weight lbs | 8 |
| Birth weight ozs | 0 |
| 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? | Yes - 2020 Right shoulder; 2020 Inner and outer right forearm |
| Have you ever had your ear(s) or body pierced? | No |
Family Medical HistoryVer lista de perguntas. here
| Mother's Father Ethnic Origins | Sicilian |
| Mother's Mother Ethnic Origins | Sicilian-Syrian |
| Father's Father Ethnic Origins | German |
| Father's Mother Ethnic Origin | Danish-Italian |
| 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 | 51 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Problemas de Saúde
Saudável
Your Father
| Question | Response |
| Current age or age at death | 56 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Problemas de Saúde
Disease
Age Diagnosed
Treatment For Condition
Other
Began taking Xanax at age 35 to treat stress
Brothers
Your Brother 1
| Question | Response |
| Current age or age at death | 13 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Problemas de Saúde
Saudável
Sisters
Your Sister 1
| 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 | COVID-19 |
Problemas de Saúde
Disease
Age Diagnosed
Treatment For Condition
Other
No other diagnosed health problems at time of death
Your Mother's Mother
| Question | Response |
| Current age or age at death | 83 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Problemas de Saúde
Disease
Age Diagnosed
Treatment For Condition
Multiple sclerosis
65
Unknown
Alzheimer's
82
Mematine
Breast cancer
75
Radiation
Your Mother's Brothers 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 Mother's Brothers 2
| Question | Response |
| Current age or age at death | 60 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Problemas de Saúde
Disease
Age Diagnosed
Treatment For Condition
Other
Lyme disease diagnosed at age 49, treated with penicillin
Your Father's Father
| Question | Response |
| Current age or age at death | 40 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Liver failure |
Problemas de Saúde
Disease
Age Diagnosed
Treatment For Condition
Other
No other diagnosed health problems at time of death
Your Father's Mother
| 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 Father's Brothers 1
| Question | Response |
| Current age or age at death | 52 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Problemas de Saúde
Saudável
Your Father's Brothers 2
| Question | Response |
| Current age or age at death | 42 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Problemas de Saúde
Saudável