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: | 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
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: | Right hip surgery; Turbinectomy - Age 19 after being hit by car, additional surgery at age 32 to correct doctor's error; Age 32 to improve breathing and reduce allergy symptoms |
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: | Protein supplement, B12, Fish Oil, Multivitamin; Claritin - Daily; As needed; Years; As needed; General Health; Seasonal Allergies |
List all current medication or treatments (include vitamins, aspirin, antacids, laxatives, herbal, sports supplements, etc.) Include drug, frequency and duration taken, and reason: | Protein supplement, B12, Fish Oil, Multivitamin; Claritin - Daily; As needed; Years; As needed; General Health; Seasonal Allergies |
Do you wear glasses or contact lenses? Are you near or far-sighted? | No |
Birth weight lbs | 6 |
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: | Yes - Pollen and ragweed (raw nose and fatigue) |
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 | Scottish |
Mother's Mother Ethnic Origins | German |
Father's Father Ethnic Origins | Welsh |
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 | 72 |
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 | 70 |
Living / Dead | Living |
Cause of death and any treatment prior to death | N/A |
Problemas de Saúde
Disease
Age Diagnosed
Treatment For Condition
Other
Underwent disc fusion surgery at age 50 to treat bulging disc
Brothers
Your Brother 1
Question | Response |
Current age or age at death | 31 |
Living / Dead | Living |
Cause of death and any treatment prior to death | N/A |
Problemas de Saúde
Saudável
Your Brother 2
Question | Response |
Current age or age at death | 29 |
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 | 90 |
Living / Dead | Dead |
Cause of death and any treatment prior to death | Old age (passed away in sleep, specific cause unknown) |
Problemas de Saúde
Disease
Age Diagnosed
Treatment For Condition
Other
No diagnosed health problems at time of death
Your Mother's Mother
Question | Response |
Current age or age at death | 94 |
Living / Dead | Dead |
Cause of death and any treatment prior to death | Pneumonia |
Problemas de Saúde
Disease
Age Diagnosed
Treatment For Condition
Other
No other diagnosed health problems at time of death
Your Mother's Sisters 1
Question | Response |
Current age or age at death | 70 |
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 | 68 |
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 | 66 |
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 | 72 |
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 | 75 |
Living / Dead | Dead |
Cause of death and any treatment prior to death | Stroke |
Problemas de Saúde
Disease
Age Diagnosed
Treatment For Condition
Dementia or degenerative disorders
75
Was showing early signs when he died, no treatment
Your Father's Mother
Question | Response |
Current age or age at death | 90 |
Living / Dead | Dead |
Cause of death and any treatment prior to death | Aneurism |
Problemas de Saúde
Disease
Age Diagnosed
Treatment For Condition
Osteoarthritis
75
Surgery on both hips
Your Father's Sisters 1
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 Father's Sisters 2
Question | Response |
Current age or age at death | 70 |
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 | 74 |
Living / Dead | Living |
Cause of death and any treatment prior to death | N/A |
Problemas de Saúde
Saudável