Personal Behavior History

Question Response
Current alcohol use:
If yes, oz./week and type of alcohol:
Occasionally - 8 oz. beer or 1 oz. bourbon
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:
Laser eye surgery, Shoulder surgery; Hip Surgery; Wisdom Teeth Extraction - Age 25, to correct vision; Age 23, tear in shoulder muscles from work related injury; Age 22, hip surgery from work related injury; Age 18, routine wisdom teeth extraction
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:Multivitamin - 1 daily; Years; General health
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 - Far-sighted, -2.25 both eyes
Birth weight lbs8
Birth weight ozs0
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 - 2021 Right Shoulder; 2021 Left Ring Finger
Have you ever had your ear(s) or body pierced?No

Family Medical History
See list of questions asked here

Mother's Father Ethnic OriginsGerman-Polish
Mother's Mother Ethnic OriginsGerman-Polish
Father's Father Ethnic OriginsGerman-Polish
Father's Mother Ethnic OriginGerman-Polish
Is anyone in your family of Ashkenazai Jewish Heritage?No
If yes, who?N/A
Question Response
Current age or age at death 56
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Question Response
Current age or age at death 57
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
50
Metformin
Question Response
Current age or age at death 34
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 0
Living / DeadLiving
Health Problems
Healthy
Question Response
Current age or age at death 86
Living / DeadDead
Cause of death and any treatment prior to deathHeart failure, no treatment
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Diabetes mellitus requiring insulin therapy
76
Insulin
Other
 
Had cataract surgery at age 80
Question Response
Current age or age at death 92
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
 
Cataracts at age 89, treated with eye drops
Question Response
Current age or age at death 60
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Question Response
Current age or age at death 62
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Question Response
Current age or age at death 56
Living / DeadDead
Cause of death and any treatment prior to deathSuicide
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Bipolar (manic depressive psychosis)
56
Medication
Suicide or suicide attempts
56
Medication for bipolar disorder was frequently changed
Question Response
Current age or age at death 70
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Question Response
Current age or age at death 30
Living / DeadDead
Cause of death and any treatment prior to deathDrug overdose
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Suicide or suicide attempts
30
None, drug overdose
Drug abuse, misuse, or addiction
30
None
Early death (less than age 50)
30
Drug overdose