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:		Frequently - Beer 36oz. /week
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, Lasic eye surgery, Wrist surgery - 17, 25 for vision correction, 27 for broken wrist
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 - Ankle at 10 from trampoline accident, Wrist at 27 fell off scooter
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 - None; None; None
List all current medication or treatments (include vitamins, aspirin, antacids, laxatives, herbal, sports supplements, etc.) Include drug, frequency and duration taken, and reason:Ibuprofen - When needed; Rarely; Aches and pain
Do you wear glasses or contact lenses?
Are you near or far-sighted?		Yes - Started at age 10, had Lasik eye surgery at 25 and no longer needs glasses
Birth weight lbs8
Birth weight ozs3
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?Yes - 2016 Rib cage; 2011 Right arm
Have you ever had your ear(s) or body pierced?Yes - 2010 Left upper ear, no longer in use

Family Medical History
See list of questions asked here

Mother's Father Ethnic OriginsGerman
Mother's Mother Ethnic OriginsNorwegian-Swedish
Father's Father Ethnic OriginsGerman
Father's Mother Ethnic OriginGerman-Swedish-English
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 52
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Gallstones
42
Gallbladder removal surgery
Diabetes mellitus requiring insulin therapy
50
Insulin
Other
 
Gestational diabetes at age 30, went away after pregnancy
Your Father
Question Response
Current age or age at death 56
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other heart disease
40
Heart valve surgery at 40 due to leaking valve, Heart valve surgery at 53 due to failure
High cholesterol
40
Diet controlled
Brothers
Your Brother 1
Question Response
Current age or age at death 25
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 21
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 40
Living / DeadDead
Cause of death and any treatment prior to deathAsthma complications
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Asthma
5
Treated with medication, did require hospitalization before death due to severe asthma attack
Your Mother's Mother
Question Response
Current age or age at death 77
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
 
Pelvic restructure surgery at age 77
Your Mother's Sisters 1
Question Response
Current age or age at death 56
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 52
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 46
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 60
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 49
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 79
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Heart attack
77
Stent and surgery
Your Father's Mother
Question Response
Current age or age at death 77
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Heart attack
70
Medication
Any other cancer/problem of digestive system
75
Intestine infection which required surgery
Your Father's Sisters 1
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 Father's Sisters 2
Question Response
Current age or age at death 59
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Your Father's Brothers 1
Question Response
Current age or age at death 53
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 49
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy