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: | Wisdom teeth extraction - Age 18 |
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 12, butterfly fracture in index finger from playing hockey, Age 14, L5 stress fracture from lifting weights |
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: | Antibiotic - 1x/day; 5 days ; Strep throat |
List all current medication or treatments (include vitamins, aspirin, antacids, laxatives, herbal, sports supplements, etc.) Include drug, frequency and duration taken, and reason: | Creatine, Magnesium - Once per day; 2 months, 2 weeks; Fitness, General Health |
Do you wear glasses or contact lenses? Are you near or far-sighted? | No |
Birth weight lbs | 6 |
Birth weight ozs | 8 |
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? | 0 |
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 | French |
Mother's Mother Ethnic Origins | French |
Father's Father Ethnic Origins | Irish |
Father's Mother Ethnic Origin | Irish |
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 | 44 |
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 | 48 |
Living / Dead | Living |
Cause of death and any treatment prior to death | N/A |
Problemas de Saúde
Saudável
Brothers
Your Brother 1
Question | Response |
Current age or age at death | 5 |
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 | 3 |
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 | 10 |
Living / Dead | Living |
Cause of death and any treatment prior to death | N/A |
Problemas de Saúde
Saudável
Your Sister 2
Question | Response |
Current age or age at death | 8 |
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 | 74 |
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 | 65 |
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 | 39 |
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 | 37 |
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 | 79 |
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 | 76 |
Living / Dead | Living |
Cause of death and any treatment prior to death | N/A |
Problemas de Saúde
Saudável