Personal Behavior History

Question Response
Current alcohol use:
If yes, oz./week and type of alcohol:
Occasionally - 12 oz. beer/wine
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

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:
N/A - N/A
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 - Left Hand, 16, High School Sport
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:N/A - N/A; N/A; N/A
List all current medication or treatments (include vitamins, aspirin, antacids, laxatives, herbal, sports supplements, etc.) Include drug, frequency and duration taken, and reason:N/A - N/A; N/A; N/A
Do you wear glasses or contact lenses?
Are you near or far-sighted?
No
Birth weight lbs8
Birth weight ozs5
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 - 2018 Left Arm; 2019 Right Arm
Have you ever had your ear(s) or body pierced?No

Family Medical History
See list of questions asked here

Mother's Father Ethnic OriginsIrish
Mother's Mother Ethnic OriginsAustrian-German
Father's Father Ethnic OriginsGerman
Father's Mother Ethnic OriginGerman
Is anyone in your family of Ashkenazai Jewish Heritage?No
If yes, who?N/A
Question Response
Current age or age at death 72
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Question Response
Current age or age at death 82
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Question Response
Current age or age at death 1
Living / DeadLiving
Health Problems
Healthy
Question Response
Current age or age at death 87
Living / DeadDead
Cause of death and any treatment prior to deathFall in the shower, heart failure
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
 
No other diagnosed health problems at time of death
Question Response
Current age or age at death 93
Living / DeadDead
Cause of death and any treatment prior to deathBreast cancer
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Breast cancer
89
Declined treatment
Question Response
Current age or age at death 28
Living / DeadDead
Cause of death and any treatment prior to deathDied in a War
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
 
No diagnosed health problems at time of death
Question Response
Current age or age at death 69
Living / DeadDead
Cause of death and any treatment prior to deathHeart attack
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
 
No other diagnosed health problems at time of death
Question Response
Current age or age at death 80
Living / DeadDead
Cause of death and any treatment prior to deathPneumonia
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
 
No other diagnosed health problems at time of death
Question Response
Current age or age at death 67
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Question Response
Current age or age at death 72
Living / DeadDead
Cause of death and any treatment prior to deathPneumonia
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
 
No other diagnosed health problems at time of death