Personal Behavior History
Donor Sexual History
Donor Genetic History
Donor Medical History
Family Medical HistoryPersonal Behavior History
| Question | Response |
| Current alcohol use: If yes, oz./week and type of alcohol: | Regularly - 32 oz. wine or beer/week |
| Have you or any of your family members been diagnosed with alcoholism or drug addiction? If yes, relation and age affected: | N/A |
| Tobacco use: Do you smoke? If yes, #/day and for how long: | No |
| If you did smoke but quit, when did you last smoke? | 2012 |
| For how many years? | 3 |
| 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 |
| Another man anal or oral, even once, since 1977? | 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: | N/A |
| Do you have learning differences, such as dyslexia? If yes, explain: | N/A |
| Were you or any family members born with any birth defects? If yes, explain: | No |
Have you or any member of your family had, currently have or been diagnosed with any of the following conditions? If yes, please list the affected individual(s), mother or father's side, age at onset, treatment and any other pertinent information.
| Heart attack | None |
| Congenital heart disease | None |
| Hemophilia/bleeding problem | None |
| Emphysema | None |
| Cystic Fibrosis | None |
| Alpha-1 Antitrypsin Deficiency | None |
| Pyloric stenosis | None |
| Colon cancer | None |
| Inflammatory bowel disease | None |
| Irritable Bowel Syndrome | None |
| Diabetes mellitus requiring insulin therapy | None |
| Diabetes mellitus not requiring insulin therapy | None |
| PKU or inherited metabolism disorder | None |
| Progressive kidney disease | None |
| Polycystic kidney disease | None |
| Miscarriages or stillborn | None |
| Herpes simplex virus, genital | None |
| Migraines | None |
| Mental retardation | None |
| Senility or mental deterioration before age 60 | None |
| Epilepsy/seizures | None |
| Neural tube defects - open spine or hydrocephalus/water on the brain | None |
| Huntington's disease | None |
| Tuberous sclerosis | None |
| Neurofibromatosis | None |
| Parkinson's disease | None |
| Down Syndrome | None |
| Autism | None |
| Autism Spectrum Disorder | None |
| Pervasive Developmental Delay (PDD) | None |
| Asperger's Syndrome | None |
| Schizophrenia | None |
| Bipolar (manic depressive psychosis) | None |
| Attention Deficit Disorder (ADD) | None |
| Attention Deficit Hyperactivity Disorder (ADHD) | None |
| Muscular Dystrophy | None |
| Loss of muscle coordination | None |
| Rheumatoid Arthritis | None |
| Reiter's Disease | None |
| Club foot | None |
| Deafness before age of 60 | None |
| Cataracts before age of 60 | None |
| Blindness in both eyes before age of 60 | None |
| Glaucoma | None |
| Macular Degeneration | None |
| Acne | None |
| Psoriasis | None |
| Albinism | None |
| More than 5 purple or coffee-colored spots on the skin-1.5 cm (1/2 inch) or larger | None |
| Drug abuse, misuse, or addiction | None |
| Cleft palate or cleft lip | None |
| Serious birth defects | None |
| Inguinal hernia | None |
| Premature degeneration of any organ system | None |
| The same cancer in more than one family member | None |
Donor Medical History
| Question | Response |
| List any operations: Age & reason: | Rhinoplasty at 20, broken nose in military |
| Hospitalization other than surgery: Age & type of illness: | N/A |
| Have you ever had any broken bones? If yes, please give age and description: | Yes - Broken nose, age 20 |
| 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 shake, three times per week |
| List all current medication or treatments (include vitamins, aspirin, antacids, laxatives, herbal, sports supplements, etc.) Include drug, frequency and duration taken, and reason: | Protein shake, three times per week |
| Do you wear glasses or contact lenses? Are you near or far-sighted? | No |
| Birth weight lbs | N/A |
| Birth weight ozs | N/A |
| Recent weight loss or gain? # of lbs and reason: | No |
| Allergies (medicines, food, pollens)? If yes, please list substance and reaction caused: | No |
| Sexual orientation: | Heterosexual |
| How many sexual partners do you currently have? | N/A |
| 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 | English, Irish, Welsh |
| Mother's Mother Ethnic Origins | English, Scot, Dutch, Welsh |
| Father's Father Ethnic Origins | N/A |
| Father's Mother Ethnic Origin | N/A |
| Is anyone in your family of Ashkenazai Jewish Heritage? | N/A |
| If yes, who? | N/A |
Your Mother
| Question | Response | Comment/Age Affected |
| Current age or age at death | 54 | |
| Health Problem | Healthy | |
| Living / Dead | Living |
Your Father
| Question | Response | Comment/Age Affected |
| Current age or age at death | 54 | |
| Health Problem | Healthy | |
| Living / Dead | Living |
Your Mother's Father
| Question | Response | Comment/Age Affected |
| Current age or age at death | 72 | |
| Health Problem | MRSA Infection, treated in hospital | 72 |
| Cause of death: MRSA infection | 72 | |
| Living / Dead | Dead |
Your Mother's Mother
| Question | Response | Comment/Age Affected |
| Current age or age at death | 70 | |
| Health Problem | Healthy | 70 |
| Living / Dead | Living |
Your Father's Father
| Question | Response | Comment/Age Affected |
| Current age or age at death | 75 | |
| Health Problem | Oral cancer, treated with surgery | 72 |
| Cause of death: Oral cancer | 75 | |
| Living / Dead | Dead |
Your Father's Mother
| Question | Response | Comment/Age Affected |
| Current age or age at death | 74 | |
| Health Problem | Healthy | |
| Living / Dead | Living |