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: | Regularly - 20-25oz. of wine |
| 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? | No - Take sleeping medicine, mostly due to poor sleep habits |
| 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 removed; LASIK - Age 18; Age 22, vision correction |
| Hospitalization other than surgery: Age & type of illness: | N/A |
| Have you ever had any broken bones? If yes, please give age and description: | Yes - Broken arm at age 13 from playing football |
| 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: | Pantoprazole, trazodone - Daily; Several years; GERD and sleep |
| List all current medication or treatments (include vitamins, aspirin, antacids, laxatives, herbal, sports supplements, etc.) Include drug, frequency and duration taken, and reason: | Zyrtec; Pantoprazole, trazodone - Daily; Daily; Several years; Several years; Season allergies; GERD and sleep |
| Do you wear glasses or contact lenses? Are you near or far-sighted? | Yes - Near-sighted, -4, -4.5 |
| Birth weight lbs | 9 |
| Birth weight ozs | 3 |
| 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? | 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 | Polish-Lithuanian |
| Mother's Mother Ethnic Origins | Lithuanian |
| Father's Father Ethnic Origins | Scottish-English |
| Father's Mother Ethnic Origin | English |
| Is anyone in your family of Ashkenazai Jewish Heritage? | Yes |
| If yes, who? | Mother |
Your Mother
| 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
| Question | Response |
| Current age or age at death | 71 |
| 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 | 34 |
| 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 | 85 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Old age (specific cause unknown) |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
Had heart valve replacement surgery, age unknown
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 | Accidental fall |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
No known diagnosed health problems at time of death
Your Mother's Sisters 1
| Question | Response |
| Current age or age at death | 75 |
| 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 | 73 |
| 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 | 92 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Alzheimer's |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
High cholesterol, age of diagnosis and treatment unknown
Your Father's Mother
| Question | Response |
| Current age or age at death | 60 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Lung Cancer |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Thyroid disease
35
Unknown
Your Father's Sisters 1
| Question | Response |
| Current age or age at death | 75 |
| 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 | 67 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy