Personal Behavior History
Donor Sexual History
Donor Genetic History
Donor Medical History
Family Medical HistoryPersonal Behavior History
| Question | Response |
| Current alcohol use: If yes, oz./week and type of alcohol: | Never |
| 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: | 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: | 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: | Advil, ibuprofen, allergy meds - As needed, As needed, As needed; No longer than a month; Headache, toothache, seasonal allergies |
| 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 lbs | 7 |
| Birth weight ozs | 6 |
| Recent weight loss or gain? # of lbs and reason: | No |
| Allergies (medicines, food, pollens)? If yes, please list substance and reaction caused: | Yes - Pollen, watery eyes and runny nose |
| 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 | Bangladeshi |
| Mother's Mother Ethnic Origins | Bangladeshi |
| Father's Father Ethnic Origins | Bangladeshi |
| Father's Mother Ethnic Origin | Bangladeshi |
| 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 | 47 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Migraines
29
Medication
Your Father
| 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
Disease
Age Diagnosed
Treatment For Condition
Asthma
8
Inhaler
Brothers
Your Brother 1
| Question | Response |
| Current age or age at death | 17 |
| 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 | 23 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Asthma
1
Inhaler
Your Mother's Father
| Question | Response |
| Current age or age at death | 94 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Old age (passed away in his sleep) |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
No known health problems at time of death
Your Mother's Mother
| Question | Response |
| Current age or age at death | 88 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Old age (passed away in nursing home) |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
Received nursing care for dementia, age of diagnosis unknown
Your Mother's Sisters 1
| Question | Response |
| Current age or age at death | 62 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Your Mother's Sisters 2
| 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 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
Healthy
Your Father's Father
| Question | Response |
| Current age or age at death | 101 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Heart 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 | 94 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Old age (passed away in sleep) |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
No known health problems at time of death
Your Father's Sisters 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 Father's Brothers 1
| 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