Personal Behavior History

Question Response
Current alcohol use:
If yes, oz./week and type of alcohol:		Occasionally - Beer
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:		Tonsillectomy; Tendon repair surgery - Age 22, frequent infection in tonsils; Age 25, from lifting weights too intensely and damaging the tendon
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 - Fingers, Wrists - Skateboarding
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, Bismuth, Multivitamins - As needed; once or twice, as needed; Sick or in general pain
List all current medication or treatments (include vitamins, aspirin, antacids, laxatives, herbal, sports supplements, etc.) Include drug, frequency and duration taken, and reason:Multivitamins - Daily; Years; General Health
Do you wear glasses or contact lenses?
Are you near or far-sighted?		No
Birth weight lbs7
Birth weight ozs4
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?0
Have you ever had a tattoo?No
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
Mother's Mother Ethnic OriginsIrish
Father's Father Ethnic OriginsSwedish
Father's Mother Ethnic OriginGerman
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 67
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Your Father
Question Response
Current age or age at death 76
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Brothers
Your Brother 1
Question Response
Current age or age at death 46
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Your Brother 2
Question Response
Current age or age at death 26
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 44
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 55
Living / DeadDead
Cause of death and any treatment prior to deathCar accident
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
 
No diagnosed health problems at time of death
Your Mother's Mother
Question Response
Current age or age at death 78
Living / DeadDead
Cause of death and any treatment prior to deathComplications following surgery
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other heart disease
65
Medication, surgery, monitoring
Your Mother's Sisters 1
Question Response
Current age or age at death 69
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Your Mother's Sisters 2
Question Response
Current age or age at death 65
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Your Mother's Sisters 3
Question Response
Current age or age at death 61
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Your Mother's Brothers 1
Question Response
Current age or age at death 65
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Your Mother's Brothers 2
Question Response
Current age or age at death 64
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Your Father's Father
Question Response
Current age or age at death 52
Living / DeadDead
Cause of death and any treatment prior to deathBrain cancer
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 91
Living / DeadDead
Cause of death and any treatment prior to deathEmphysema
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
 
No other diagnosed health problems at time of death
Your Father's Sisters 1
Question Response
Current age or age at death 78
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Your Father's Sisters 2
Question Response
Current age or age at death 73
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Your Father's Brothers 1
Question Response
Current age or age at death 74
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy