This donor is a healthy carrier for a genetic disease.
Please see his Genetic Testing Summary and Acknowledgment of Genetic Risk for details
Please see his Genetic Testing Summary and Acknowledgment of Genetic Risk for details
Personal Behavior History
Question | Response |
Current alcohol use: If yes, oz./week and type of alcohol: | Rarely - 1 oz. Gin |
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: | Tooth removal; Wisdom teeth extraction - Age 14, tooth removal before getting braces: Age 22, Routine procedure |
Hospitalization other than surgery: Age & type of illness: | None - 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: | Protein powder - Daily; 6 months; Nutrition supplements |
List all current medication or treatments (include vitamins, aspirin, antacids, laxatives, herbal, sports supplements, etc.) Include drug, frequency and duration taken, and reason: | Multi-vitamin - Daily; 6 months; Daily vitamins |
Do you wear glasses or contact lenses? Are you near or far-sighted? | No |
Birth weight lbs | 5 |
Birth weight ozs | 5 |
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 Left calf; 2016 Calf; 2018 Left calf; 2022 Right chest |
Have you ever had your ear(s) or body pierced? | Yes - 2015 Left ear; 2022 Right nipple |
Family Medical HistorySee list of questions asked here
Mother's Father Ethnic Origins | Swedish-Norwegian |
Mother's Mother Ethnic Origins | Swedish-Norwegian |
Father's Father Ethnic Origins | Polish |
Father's Mother Ethnic Origin | Polish |
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 | 57 |
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 | 57 |
Living / Dead | Living |
Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Brothers
Your Brother 1
Question | Response |
Current age or age at death | 32 |
Living / Dead | Living |
Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Your Brother 2
Question | Response |
Current age or age at death | 27 |
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 | 84 |
Living / Dead | Living |
Cause of death and any treatment prior to death | N/A |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other heart disease
84
Heart valve surgery
Your Mother's Mother
Question | Response |
Current age or age at death | 80 |
Living / Dead | Living |
Cause of death and any treatment prior to death | N/A |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
Hip replacement surgery at 75
Your Mother's Sisters 1
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
Healthy
Your Mother'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
Your Father's Father
Question | Response |
Current age or age at death | 84 |
Living / Dead | Dead |
Cause of death and any treatment prior to death | Heart failure |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Heart attack
30
None
Other
Had two additional heart attacks at 50 and 60. Was a smoker.
Your Father's Mother
Question | Response |
Current age or age at death | 65 |
Living / Dead | Dead |
Cause of death and any treatment prior to death | Lung cancer, radiation and surgery |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Lung cancer
58
Radiation and lung removal surgery, was smoker
Your Father's Sisters 1
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 Father's Sisters 2
Question | Response |
Current age or age at death | 52 |
Living / Dead | Dead |
Cause of death and any treatment prior to death | Stroke |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
No other diagnosed health problems at time of death
Your Father's Sisters 3
Question | Response |
Current age or age at death | 50 |
Living / Dead | Living |
Cause of death and any treatment prior to death | N/A |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
Liver disease, age of diagnosis and treatment unknown
Your Father's Brothers 1
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
Healthy
Your Father's Brothers 2
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
Your Father's Brothers 3
Question | Response |
Current age or age at death | 50 |
Living / Dead | Dead |
Cause of death and any treatment prior to death | Suicide |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Suicide or suicide attempts
50
None, took his own life after his son died at age 18 in a car accident