Doador 6929 - Medical Profile

Personal Behavior History

Question	Response
Current alcohol use: If yes, oz./week and type of alcohol:	Never
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:	N/A - N/A
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:	No
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:	N/A - 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:	N/A - N/A; N/A; N/A
Do you wear glasses or contact lenses? Are you near or far-sighted?	Yes - Near-sighted, -2.75 both eyes
Birth weight lbs	9
Birth weight ozs	10
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 History
Ver lista de perguntas. here

Mother's Father Ethnic Origins	Italian
Mother's Mother Ethnic Origins	Italian
Father's Father Ethnic Origins	German-Irish
Father's Mother Ethnic Origin	European
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	52
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	52
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

Better diet and Medication

Sisters

Your Sister 1

Question	Response
Current age or age at death	28
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	73
Living / Dead	Living
Cause of death and any treatment prior to death	N/A

Problemas de Saúde

Saudável

Your Mother's Mother

Question	Response
Current age or age at death	76
Living / Dead	Living
Cause of death and any treatment prior to death	N/A

Problemas de Saúde

Saudável

Your Mother's Sisters 1

Question	Response
Current age or age at death	55
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	54
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	48
Living / Dead	Living
Cause of death and any treatment prior to death	N/A

Problemas de Saúde

Saudável

Your Mother's Brothers 1

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

Saudável

Your Mother's Brothers 2

Question	Response
Current age or age at death	57
Living / Dead	Living
Cause of death and any treatment prior to death	N/A

Problemas de Saúde

Saudável

Your Father's Father

Question	Response
Current age or age at death	74
Living / Dead	Living
Cause of death and any treatment prior to death	N/A

Problemas de Saúde

Saudável

Your Father's Mother

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

Saudável

Your Father's Sisters 1

Question	Response
Current age or age at death	40
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	41
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	25
Living / Dead	Dead
Cause of death and any treatment prior to death	Car accident

Problemas de Saúde

Disease

Age Diagnosed

Treatment For Condition

Other

No diagnosed health problems at time of death

Número do Doador: 6929

Personal Behavior History

Sexual History

Donor Genetic History

Donor Medical History

Family Medical HistoryVer lista de perguntas. here

Family Medical History
Ver lista de perguntas. here