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: | Occasionally - 1 oz./week tequila |
| 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: | Tonsillectomy - Age 12, recommended by doctor |
| 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 - Hairline fracture right pinky toe |
| 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: | Whey protein - 3-5 times a week; 6 months; Exercise and Health Benefits |
| List all current medication or treatments (include vitamins, aspirin, antacids, laxatives, herbal, sports supplements, etc.) Include drug, frequency and duration taken, and reason: | Whey protein - 3-5 times a week; 6 months; Exercise and Health Benefits |
| Do you wear glasses or contact lenses? Are you near or far-sighted? | No |
| Birth weight lbs | 6 |
| Birth weight ozs | 8 |
| Recent weight loss or gain? # of lbs and reason: | Yes - Lost 20 lbs, Diet and exercise. |
| 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 Left Calf; 2019 Left Ankle |
| Have you ever had your ear(s) or body pierced? | No |
Family Medical HistorySee list of questions asked here
| Mother's Father Ethnic Origins | Venezuelan |
| Mother's Mother Ethnic Origins | Venezuelan |
| Father's Father Ethnic Origins | Peruvian |
| Father's Mother Ethnic Origin | Peruvian |
| 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 | 64 |
| 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 | 66 |
| 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 | 36 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Sons
Your Son 1
| Question | Response |
| Current age or age at death | 3 |
| Living / Dead | Living |
Health Problems
Healthy
Your Mother's Father
| Question | Response |
| Current age or age at death | 40 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Car Accident |
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 | 81 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Multiple Organ Failure resulting from surgical infection. |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
Infection from hip surgery became severe and caused organ failure at age 81
Your Father's Father
| Question | Response |
| Current age or age at death | 78 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Kidney Failure, dialysis |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other disease of the kidney, urinary tract, urethra, bladder, ureter
68
Was on dialysis due to smoking, was a heavy smoker.
Your Father's Mother
| Question | Response |
| Current age or age at death | 86 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Stroke
74
IV Medication
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 | 58 |
| 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 | 61 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Your Father's Brothers 2
| 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