Personal Behavior History

Question Response
Current alcohol use:
If yes, oz./week and type of alcohol:		Frequently - Two beers per week (24oz.)
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:		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:		Yes - Age 35, clavicle and scapula, mountain biking related injury
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?		No
Birth weight lbs8
Birth weight ozs9
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 - 5 tattoos: 2016 left arm, 2006 left arm, 2010 right arm, 2016 right deltoid, 2020 back
Have you ever had your ear(s) or body pierced?No

Family Medical History
Ver lista de perguntas. here

Mother's Father Ethnic OriginsIranian
Mother's Mother Ethnic OriginsIranian
Father's Father Ethnic OriginsTurkish
Father's Mother Ethnic OriginIranian
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 66
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Problemas de Saúde
Saudável
Your Father
Question Response
Current age or age at death 76
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Problemas de Saúde
Saudável
Brothers
Your Brother 1
Question Response
Current age or age at death 46
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Problemas de Saúde
Saudável
Your Mother's Father
Question Response
Current age or age at death 88
Living / DeadDead
Cause of death and any treatment prior to deathHeart Failure
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 90
Living / DeadDead
Cause of death and any treatment prior to deathHeart Failure
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 60
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Problemas de Saúde
Saudável
Your Mother's Sisters 2
Question Response
Current age or age at death 58
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Problemas de Saúde
Saudável
Your Mother's Brothers 1
Question Response
Current age or age at death 67
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Problemas de Saúde
Saudável
Your Mother's Brothers 2
Question Response
Current age or age at death 55
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Problemas de Saúde
Saudável
Your Father's Father
Question Response
Current age or age at death 97
Living / DeadDead
Cause of death and any treatment prior to deathHeart 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 40
Living / DeadDead
Cause of death and any treatment prior to deathFarm Machine Accident
Problemas de Saúde
Disease
Age Diagnosed
Treatment For Condition
Other
 
No other diagnosed health problems at time of death
Your Father's Sisters 1
Question Response
Current age or age at death 64
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Problemas de Saúde
Saudável
Your Father's Sisters 2
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
Your Father's Brothers 1
Question Response
Current age or age at death 70
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Problemas de Saúde
Saudável
Your Father's Brothers 2
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
Your Father's Brothers 3
Question Response
Current age or age at death 58
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Problemas de Saúde
Saudável
Your Father's Brothers 4
Question Response
Current age or age at death 55
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Problemas de Saúde
Saudável
Your Father's Brothers 5
Question Response
Current age or age at death 45
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Problemas de Saúde
Saudável