Personal Behavior History

Question Response
Current alcohol use:
If yes, oz./week and type of alcohol:		Rarely - 1 drink per 2 weeks. Tequila.
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:		Appendix removed - Age 12, appendicitis
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:		No
Have you ever had any serious illnesses?
If yes, please give age and description:		Yes - Age 28, COVID-19, treated with medication and rest
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, Tylenol - As needed; As needed; Headache
List all current medication or treatments (include vitamins, aspirin, antacids, laxatives, herbal, sports supplements, etc.) Include drug, frequency and duration taken, and reason:Daily vitamin - Daily; 6 months; General Health
Do you wear glasses or contact lenses?
Are you near or far-sighted?		Yes - Near-sighted, 2.00/2.25
Birth weight lbs7
Birth weight ozs14
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 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 49
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 57
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
Sisters
Your Sister 1
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 Sister 2
Question Response
Current age or age at death 13
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Your Sister 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 77
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Your Mother'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 Mother's Sisters 1
Question Response
Current age or age at death 50
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 45
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 43
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 33
Living / DeadDead
Cause of death and any treatment prior to deathWork Accident
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
 
No diagnosed health problems at time of death
Your Father's Mother
Question Response
Current age or age at death 66
Living / DeadDead
Cause of death and any treatment prior to deathComplications following surgery
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other heart disease
60
Coronary artery disease, complications from surgery led to death
Your Father's Sisters 1
Question Response
Current age or age at death 48
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 Father's Sisters 2
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 Father's Sisters 3
Question Response
Current age or age at death 43
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 58
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Your Father's Brothers 2
Question Response
Current age or age at death 54
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy