Personal Behavior History

Question Response
Current alcohol use:
If yes, oz./week and type of alcohol:		Occasionally - 2 oz./week 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?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:		ACL Reconstruction and Meniscus Repairs - Ages 15 and 20, both injuries from football
Hospitalization other than surgery:
Age & type of illness:		Gunshot Wound - Age 18, trauma
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:Creatine, Daily Vitamin, Vitamin D3, Zinc Magnesium Aspertate - Daily; 1 year; Health and athletic performance
List all current medication or treatments (include vitamins, aspirin, antacids, laxatives, herbal, sports supplements, etc.) Include drug, frequency and duration taken, and reason:Creatine, Daily Vitamin, Vitamin D3, Zinc Magnesium Aspertate - Daily; 1 year; Health and athletic performance
Do you wear glasses or contact lenses?
Are you near or far-sighted?		Yes - Near-sighted, -4 both eyes
Birth weight lbs7
Birth weight ozs8
Recent weight loss or gain?
# of lbs and reason:		Yes - 20 lbs. to gain muscle mass
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 - 2014 Left Chest; 2016 Upper Right arm; 2019 Upper Left arm; 2020 Right inner bicep; 2021 Right inner forearm; 2021 Right outer forearm; 2022 Right elbow; 2022 Left elbow; 2022 Left knee; 2022 Right thigh
Have you ever had your ear(s) or body pierced?Yes - 2015 Earlobes; 2019 Left nostril

Family Medical History
See list of questions asked here

Mother's Father Ethnic OriginsAfrican American
Mother's Mother Ethnic OriginsAfrican American
Father's Father Ethnic OriginsAfrican American
Father's Mother Ethnic OriginAfrican American
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 48
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Stroke
49
blood thinners and blood pressure medication
Your Father
Question Response
Current age or age at death 48
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 31
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 21
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 12
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 70
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Prostate cancer
70
Radiation treatment
Your Mother's Mother
Question Response
Current age or age at death 50
Living / DeadDead
Cause of death and any treatment prior to deathLiver Failure
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Heart attack
50
N/A
Other
 
No other diagnosed health problems at time of death
Your Mother's Sisters 1
Question Response
Current age or age at death 32
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 36
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 31
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 72
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Your Father's 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's Sisters 1
Question Response
Current age or age at death 55
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 45
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Breast cancer
35
Chemotherapy
Other
 
Recent reoccurrence of breast cancer that has metastasized to liver
Your Father's Brothers 1
Question Response
Current age or age at death 48
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy