Personal Behavior History

Question Response
Current alcohol use:
If yes, oz./week and type of alcohol:		Frequently - 24 oz. Beer per week
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:		Wisdom Teeth Removal - Age 18, all 4 wisdom teeth removed
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 - Age 18, left middle finger metacarpal, I dove while playing ultimate frisbee to catch the frisbee.
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:N/A - N/A; N/A; N/A
List all current medication or treatments (include vitamins, aspirin, antacids, laxatives, herbal, sports supplements, etc.) Include drug, frequency and duration taken, and reason:Men's multivitamin, calcium supplements, and magnesium supplements. - Daily; 1 year; To maintain a healthy diet
Do you wear glasses or contact lenses?
Are you near or far-sighted?		Yes - Near-sighted, 20/40
Birth weight lbs7
Birth weight ozs13
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 - 2020 Left Shoulder
Have you ever had your ear(s) or body pierced?No

Family Medical History
See list of questions asked here

Mother's Father Ethnic OriginsSwedish
Mother's Mother Ethnic OriginsNorweigian
Father's Father Ethnic OriginsRussian
Father's Mother Ethnic OriginEnglish
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 58
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
 
Chronic back pain, no treatment
Your Father
Question Response
Current age or age at death 62
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Prostate cancer
60
Medication
Brothers
Your Brother 1
Question Response
Current age or age at death 36
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 31
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Your Brother 3
Question Response
Current age or age at death 30
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Gallstones
30
Gallbladder removed
Your Brother 4
Question Response
Current age or age at death 27
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Your Brother 5
Question Response
Current age or age at death 21
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Your Brother 6
Question Response
Current age or age at death 18
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 33
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 66
Living / DeadDead
Cause of death and any treatment prior to deathStomach Cancer, lifelong smoker
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Stomach Cancer
64
Chemotherapy and radiation
Your Mother's Mother
Question Response
Current age or age at death 82
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Your Mother's Sisters 1
Question Response
Current age or age at death 59
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 56
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 54
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Breast cancer
50
Chemotherapy and lumpectomy
Your Father's Father
Question Response
Current age or age at death 84
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Heart attack
80
Stents and pacemaker
Your Father's Mother
Question Response
Current age or age at death 64
Living / DeadDead
Cause of death and any treatment prior to deathBreast Cancer
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Breast cancer
62
Chemotherapy and double mastectomy
Your Father's Sisters 1
Question Response
Current age or age at death 64
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Drug abuse, misuse, or addiction
17
Age 17-24, Alcoholism, sober now
Your Father's Brothers 1
Question Response
Current age or age at death 59
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy