Personal Behavior History
Donor Sexual History
Donor Genetic History
Donor Medical History
Family Medical HistoryUpdated medical information on the donor and his family (if applicable) will be included at the bottom of the Summary Profile
Personal Behavior History
| Question | Response |
| Current alcohol use: If yes, oz./week and type of alcohol: | Regularly - 48 oz./week, beer |
| 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: | Inguinal hernia repair - Less than 1, to repair hernia in abdomen |
| 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: | No |
| 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: | Asprin - As needed; As needed; Deal with headache or sore muscles |
| List all current medication or treatments (include vitamins, aspirin, antacids, laxatives, herbal, sports supplements, etc.) Include drug, frequency and duration taken, and reason: | Mutivitamin - Daily; 10 years; Maintain balanced health |
| Do you wear glasses or contact lenses? Are you near or far-sighted? | Yes - Near-sighted, -2.5 both |
| Birth weight lbs | 6 |
| Birth weight ozs | 1 |
| 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 | English |
| Mother's Mother Ethnic Origins | English-German |
| Father's Father Ethnic Origins | Irish |
| Father's Mother Ethnic Origin | 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 | 69 |
| 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 | 64 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Esophageal Cancer |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Kidney Stones
61
Ultrasound therapy, diet changes
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
Your Mother's Father
| Question | Response |
| Current age or age at death | 87 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Stroke, no treatment |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
No other diagnosed health problems at time of death
Your Mother's Mother
| Question | Response |
| Current age or age at death | 92 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Infection developed after injury from fall |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Any other sight/sound/smell disorder
80
Cataracts, treated with surgery
Your Mother's Brothers 1
| Question | Response |
| Current age or age at death | 67 |
| 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 | 65 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | COPD (smoker) |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
Used an oxygen tank to treat emphysema (age of diagnosis unknown)
Your Mother's Brothers 3
| Question | Response |
| Current age or age at death | 55 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Emphysema |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
No other diagnosed health problems at time of death
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 | Liver failure |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
No other diagnosed health problems at time of death
Your Father's Mother
| Question | Response |
| Current age or age at death | 70 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Pneumonia |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Breast cancer
55
Chemotherapy and radiation
Your Father's Sisters 1
| 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 Father's Sisters 2
| Question | Response |
| Current age or age at death | 64 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Specific cause unknown, poor lifestyle, avoided doctors |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
Suffered a back injury (age unknown) that prevented her from working
Your Father's Sisters 3
| Question | Response |
| Current age or age at death | 63 |
| 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 | 75 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy