Personal Behavior History

Question Response
Current alcohol use:
If yes, oz./week and type of alcohol:		Rarely - 12 oz. beer (1 drink a month)
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 - Age 18, was done to prevent crowding of teeth
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 - Age 4, broke leg bone, fell off while riding my dog; Age 15, broke arm in bike accident; Age 22, broke collarbone in car accident
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:I have some cannabis edibles when I go to New York for work - 8/year; 1 week; Recreation
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?		Yes - Near-sighted, -3:-1.25/-3.5:-1.75
Birth weight lbs7
Birth weight ozs12
Recent weight loss or gain?
# of lbs and reason:		Yes - Lost 35 pounds, started exercising, wanted to feel healthier
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 - 2017 Upper Thigh, Left Wrist, Left Forearm, Chest, Left Elbow, Right Upper 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 OriginsScandinavian
Mother's Mother Ethnic OriginsNorwegian
Father's Father Ethnic OriginsSwedish
Father's Mother Ethnic OriginEnglish
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 53
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Osteoarthritis
40
Medication
Your Father
Question Response
Current age or age at death 54
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Diabetes mellitus not requiring insulin therapy
52
Diet controlled
Brothers
Your Brother 1
Question Response
Current age or age at death 22
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 19
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 83
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Your Mother's Mother
Question Response
Current age or age at death 89
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Any other sight/sound/smell disorder
89
Cochlear implant for age-related hearing loss
Your Mother's Sisters 1
Question Response
Current age or age at death 46
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Eczema
39
Topical cream as needed
Your Father's Father
Question Response
Current age or age at death 57
Living / DeadDead
Cause of death and any treatment prior to deathLung cancer from gulf war burn pits
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Lung cancer
56
None, advanced diagnoses
Your Father's Mother
Question Response
Current age or age at death 89
Living / DeadDead
Cause of death and any treatment prior to deathAlzheimer's
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Alzheimer's
87
Medication and home care
Your Father's Brothers 1
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 2
Question Response
Current age or age at death 58
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Your Father's Brothers 3
Question Response
Current age or age at death 57
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Your Father's Brothers 4
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 Father's Brothers 5
Question Response
Current age or age at death 37
Living / DeadDead
Cause of death and any treatment prior to deathLung Cancer (burn pit exposure)
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Lung cancer
27
Chemotherapy