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 tooth (1) extraction - 25 |
Hospitalization other than surgery: Age & type of illness: | None - None |
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 powder, Pre-workout - 5-6 times a week; For about a decade; Fitness |
List all current medication or treatments (include vitamins, aspirin, antacids, laxatives, herbal, sports supplements, etc.) Include drug, frequency and duration taken, and reason: | Multivitamin, Vitamin D, C, omega 3s, iron, niacin, calcium/magnesium/zinc - Daily; N/A; Health/fitness |
Do you wear glasses or contact lenses? Are you near or far-sighted? | Yes - Near-sighted, -5.5 both eyes |
Birth weight lbs | 8 |
Birth weight ozs | 1 |
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 HistorySee list of questions asked here
Mother's Father Ethnic Origins | Scottish |
Mother's Mother Ethnic Origins | Irish |
Father's Father Ethnic Origins | British |
Father's Mother Ethnic Origin | British |
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 | 61 |
Living / Dead | Living |
Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Your Father
Question | Response |
Current age or age at death | 65 |
Living / Dead | Living |
Cause of death and any treatment prior to death | N/A |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
High blood pressure
60
Medication
Brothers
Your Brother 1
Question | Response |
Current age or age at death | 38 |
Living / Dead | Living |
Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Sisters
Your Sister 1
Question | Response |
Current age or age at death | 43 |
Living / Dead | Living |
Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Your Sister 2
Question | Response |
Current age or age at death | 41 |
Living / Dead | Living |
Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Your Sister 3
Question | Response |
Current age or age at death | 40 |
Living / Dead | Living |
Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
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 | Kidney Disease |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
Diagnosed with kidney disease in 1993, caused by exposure to industrial chemicals and treated with dialysis
Your Mother's Mother
Question | Response |
Current age or age at death | 80 |
Living / Dead | Dead |
Cause of death and any treatment prior to death | Lung Cancer (smoker) |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Lung cancer
75
Chemotherapy and radiation
Your Mother's Sisters 1
Question | Response |
Current age or age at death | 72 |
Living / Dead | Living |
Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Your Mother's Sisters 2
Question | Response |
Current age or age at death | 69 |
Living / Dead | Living |
Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
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 |
Health Problems
Healthy
Your Mother's Sisters 4
Question | Response |
Current age or age at death | 65 |
Living / Dead | Living |
Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Your Mother's Sisters 5
Question | Response |
Current age or age at death | 62 |
Living / Dead | Living |
Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Your Mother's Brothers 1
Question | Response |
Current age or age at death | 67 |
Living / Dead | Living |
Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Your Father's Father
Question | Response |
Current age or age at death | 85 |
Living / Dead | Dead |
Cause of death and any treatment prior to death | Emphysema (smoker) |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
Diagnosed with COPD in 2017, treated with medication
Your Father's Mother
Question | Response |
Current age or age at death | 80 |
Living / Dead | Living |
Cause of death and any treatment prior to death | N/A |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Diabetes mellitus requiring insulin therapy
60
Insulin
Your Father's Sisters 1
Question | Response |
Current age or age at death | 60 |
Living / Dead | Living |
Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Your Father's Sisters 2
Question | Response |
Current age or age at death | 50 |
Living / Dead | Living |
Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy