Personal Behavior History
Donor Sexual History
Donor Genetic History
Donor Medical History
Family Medical HistoryThis 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: | Pneumothorax correction at age 13 to correct pneumothorax caused by bike accident; Wisdom teeth extraction (2 teeth) at age 17 - N/A |
| Hospitalization other than surgery: Age & type of illness: | None - N/A |
| Have you ever had any broken bones? If yes, please give age and description: | Yes - Broken collar bone at age 9 due to fall on sidewalk |
| 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: | None - 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: | None - N/A; N/A; N/A |
| Do you wear glasses or contact lenses? Are you near or far-sighted? | Yes - 20/600 |
| Birth weight lbs | 5 |
| Birth weight ozs | 2 |
| Recent weight loss or gain? # of lbs and reason: | No |
| Allergies (medicines, food, pollens)? If yes, please list substance and reaction caused: | Yes - Dust: Sneezing; Pollen: Sneezing |
| 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 HistorySee list of questions asked here
| Mother's Father Ethnic Origins | Bangladeshi |
| Mother's Mother Ethnic Origins | Bangladeshi |
| Father's Father Ethnic Origins | Bangladeshi |
| Father's Mother Ethnic Origin | Bangladeshi |
| 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 | 53 |
| 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
44
No treatment
High cholesterol
44
Dietary changes
Diabetes mellitus not requiring insulin therapy
44
Dietary changes
Your Father
| Question | Response |
| Current age or age at death | 64 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Heart attack
64
Surgery to place stent
High blood pressure
44
Medication
Ulcer of stomach/duodenum
55
Dietary changes
Brothers
Your Brother 1
| Question | Response |
| Current age or age at death | 26 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Asthma
6
Seasonal at home nebulizer when needed; Outgrew in teenage years.
Your Brother 2
| Question | Response |
| Current age or age at death | 17 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Asthma
6
Seasonal at home nebulizer when needed; Outgrew in teenage years.
Eczema
14
Topical medication
Sisters
Your Sister 1
| Question | Response |
| Current age or age at death | 25 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Acne
13
Skin care regimen
Your Mother's Father
| Question | Response |
| Current age or age at death | 70 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | General health decline |
Health Problems
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 | 69 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Dementia |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Dementia or degenerative disorders
68
Medication
Your Mother's Sisters 1
| Question | Response |
| Current age or age at death | 52 |
| 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 | 75 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Your Mother's Brothers 2
| Question | Response |
| Current age or age at death | 70 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Your Mother's Brothers 3
| Question | Response |
| Current age or age at death | 69 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Construction accident |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
No diagnosed health problems at time of death.
Your Mother's Brothers 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 Brothers 5
| 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 Father
| Question | Response |
| Current age or age at death | 70 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Failure in health after years of hard labor |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
No health problems diagnosed at time of death.
Your Father's Mother
| Question | Response |
| Current age or age at death | 85 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Your Father's Sisters 1
| Question | Response |
| Current age or age at death | 65 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Diabetes |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Diabetes mellitus requiring insulin therapy
60
Insulin
Your Father's Sisters 2
| Question | Response |
| Current age or age at death | 52 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Pneumonia, hospitalization |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
No other health problems diagnosed at time of death
Your Father's Sisters 3
| 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
Your Father's Brothers 1
| Question | Response |
| Current age or age at death | 56 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Diabetes mellitus not requiring insulin therapy
51
Dietary changes and increased activity
Your Father's Brothers 2
| Question | Response |
| Current age or age at death | 55 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Diabetes mellitus not requiring insulin therapy
54
Dietary changes and increased activity
Your Father's Brothers 3
| Question | Response |
| Current age or age at death | 54 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Your Father's Brothers 4
| Question | Response |
| Current age or age at death | 53 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy