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: | Rarely - 1 oz. whiskey/vodka |
| 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: | Broken thumb; meniscus repair - Age 17, playing football; age 28, torn meniscus |
| Hospitalization other than surgery: Age & type of illness: | None - None |
| Have you ever had any broken bones? If yes, please give age and description: | Yes - 17, broken thumb, football |
| 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: | Creatine, Tylenol - 8 oz/day; 1 month; Wellness, headache |
| List all current medication or treatments (include vitamins, aspirin, antacids, laxatives, herbal, sports supplements, etc.) Include drug, frequency and duration taken, and reason: | Creatine - 8oz/day; 1 month; Wellness |
| Do you wear glasses or contact lenses? Are you near or far-sighted? | Yes - Near-sighted, 20/200 |
| Birth weight lbs | 8 |
| Birth weight ozs | 8 |
| 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 HistorySee list of questions asked here
| Mother's Father Ethnic Origins | Polish-Irish |
| Mother's Mother Ethnic Origins | German-Polish-Irish |
| Father's Father Ethnic Origins | German-Polish |
| Father's Mother Ethnic Origin | Polish-Irish |
| 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 | 55 |
| 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 | 54 |
| 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 | 24 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Your Mother's Father
| Question | Response |
| Current age or age at death | 59 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Flu |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Lung cancer
58
Chemotherapy
Your Mother's Mother
| 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 1
| 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
Disease
Age Diagnosed
Treatment For Condition
Colon cancer
54
Surgery
Your Father's Father
| Question | Response |
| Current age or age at death | 62 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Heart Failure |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
Diagnosed with poor lung function due to smoking at age 65, received oxygen as treatment
Your Father's Mother
| Question | Response |
| Current age or age at death | 72 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Lung Failure, smoker, COPD |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
Diagnosed with COPD at age 70, treated with oxygen and protein IV
Your Father's Sisters 1
| Question | Response |
| Current age or age at death | 57 |
| 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 | 59 |
| 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 | 56 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | COVID-19 |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Heart attack
51
Suffered four heart attacks at ages 51, 52, 53, and 54, treated with hospitalization and medication