This donor is a healthy carrier for a genetic disease.
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:		Occasionally - Beer/wine on nights out or special occasions
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:		None - 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:		No
Have you ever had any serious illnesses?
If yes, please give age and description:		Yes - 19, had Mono once
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:Daily multivitamin - Most days; Last few years; General health/diet
List all current medication or treatments (include vitamins, aspirin, antacids, laxatives, herbal, sports supplements, etc.) Include drug, frequency and duration taken, and reason:Daily multivitamin - Most days; Last few years; General health/diet
Do you wear glasses or contact lenses?
Are you near or far-sighted?		Yes - -1.50/-1.25
Birth weight lbs10
Birth weight ozs10
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?No
Have you ever had your ear(s) or body pierced?No

Family Medical History
See list of questions asked here

Mother's Father Ethnic OriginsGerman-Polish
Mother's Mother Ethnic OriginsNorwegian
Father's Father Ethnic OriginsGerman
Father's Mother Ethnic OriginAustrian-Hungarian
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 62
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Your Father
Question Response
Current age or age at death 61
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Brothers
Your Brother 1
Question Response
Current age or age at death 29
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Your Brother 2
Question Response
Current age or age at death 27
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Sisters
Your Sister 1
Question Response
Current age or age at death 45
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Your Sister 2
Question Response
Current age or age at death 40
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Your Mother's Father
Question Response
Current age or age at death 82
Living / DeadDead
Cause of death and any treatment prior to deathHeart failure
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other heart disease
65
Surgery
High blood pressure
57
Medication
Your Mother's Mother
Question Response
Current age or age at death 89
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Your Mother's Sisters 1
Question Response
Current age or age at death 69
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Your Mother's Sisters 2
Question Response
Current age or age at death 66
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Your Mother's Sisters 3
Question Response
Current age or age at death 64
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Your Mother's Sisters 4
Question Response
Current age or age at death 61
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
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
Health Problems
Healthy
Your Mother's Brothers 2
Question Response
Current age or age at death 58
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Your Father's Father
Question Response
Current age or age at death 83
Living / DeadDead
Cause of death and any treatment prior to deathHeart failure
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Stroke
78
Medication, Assisted Care, Physical Therapy
Your Father's Mother
Question Response
Current age or age at death 73
Living / DeadDead
Cause of death and any treatment prior to deathKidney failure from having Hepatitis C
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
 
Hepatitis C at age 49 from a blood transfusion, no treatment
Your Father's Sisters 1
Question Response
Current age or age at death 68
Living / DeadDead
Cause of death and any treatment prior to deathBone Cancer, chemotherapy and radiation
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Bipolar (manic depressive psychosis)
40
Medication
Other
 
Bone cancer, diagnosed age 53, treated with chemotherapy and radiation
Your Father's Sisters 2
Question Response
Current age or age at death 67
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Your Father's Sisters 3
Question Response
Current age or age at death 50
Living / DeadDead
Cause of death and any treatment prior to deathSuicide
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Depression
50
Unknown
Your Father's Brothers 1
Question Response
Current age or age at death 79
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Your Father's Brothers 2
Question Response
Current age or age at death 75
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy