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: | Frequently - 24oz. beer |
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: | Wisdom teeth extraction; Septoplasty - Age 18, routine procedure; Age 23, deviated septum |
Hospitalization other than surgery: Age & type of illness: | Appendicitis - Age22, had COVID-19 and appendix got inflamed, successful treatment with antibiotics. Was not removed. |
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: | Vitamin D - Daily; 5 years; General wellness |
Do you wear glasses or contact lenses? Are you near or far-sighted? | No |
Birth weight lbs | 8 |
Birth weight ozs | 6 |
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 Leg |
Have you ever had your ear(s) or body pierced? | Yes - 2020 Nipple |
Family Medical HistoryVer lista de perguntas. here
Mother's Father Ethnic Origins | German |
Mother's Mother Ethnic Origins | German |
Father's Father Ethnic Origins | German |
Father's Mother Ethnic Origin | German |
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 | 61 |
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 | 25 |
Living / Dead | Living |
Cause of death and any treatment prior to death | N/A |
Problemas de Saúde
Disease
Age Diagnosed
Treatment For Condition
Other
Tonsil removal at age 5
Your Sister 2
Question | Response |
Current age or age at death | 20 |
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 | 78 |
Living / Dead | Dead |
Cause of death and any treatment prior to death | Renal Failure |
Problemas de Saúde
Disease
Age Diagnosed
Treatment For Condition
High blood pressure
70
Medication
Other lung disease
75
COPD treated with medication
Your Mother's Mother
Question | Response |
Current age or age at death | 88 |
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 | 57 |
Living / Dead | Living |
Cause of death and any treatment prior to death | N/A |
Problemas de Saúde
Disease
Age Diagnosed
Treatment For Condition
Breast cancer
45
Chemotherapy and surgery
Your Mother's Sisters 2
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
Saudável
Your Mother's Sisters 3
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 Brothers 1
Question | Response |
Current age or age at death | 53 |
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 | 88 |
Living / Dead | Dead |
Cause of death and any treatment prior to death | Heart failure |
Problemas de Saúde
Disease
Age Diagnosed
Treatment For Condition
Prostate cancer
65
Surgery and chemotherapy
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
Disease
Age Diagnosed
Treatment For Condition
Emphysema
81
Oxygen tank
Your Father's Sisters 1
Question | Response |
Current age or age at death | 68 |
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 | 50 |
Living / Dead | Dead |
Cause of death and any treatment prior to death | Drug Overdose |
Problemas de Saúde
Disease
Age Diagnosed
Treatment For Condition
Drug abuse, misuse, or addiction
35
None
Your Father's Brothers 1
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
Saudável