Personal Behavior History

Question Response
Current alcohol use:
If yes, oz./week and type of alcohol:		Never
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:		N/A - N/A
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:		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:Protein powder - 1x per day; Since age 18; Extra protein for workouts
Do you wear glasses or contact lenses?
Are you near or far-sighted?		No
Birth weight lbs8
Birth weight ozs6
Recent weight loss or gain?
# of lbs and reason:		No
Allergies (medicines, food, pollens)?
If yes, please list substance and reaction caused:		Yes - Amoxicillin, caused a mild rash as a child. Have not taken it since then.
How many sexual partners do you currently have?1
Have you ever had a tattoo?Yes - 2013 Right arm; 2013 Upper center chest; 2015 Left arm
Have you ever had your ear(s) or body pierced?Yes - 2011 Right ear; 2011 Left ear

Family Medical History
See list of questions asked here

Mother's Father Ethnic OriginsNative American-African American
Mother's Mother Ethnic OriginsNative American-African 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
Healthy
Your Father
Question Response
Current age or age at death 55
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 34
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 19
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 80
Living / DeadDead
Cause of death and any treatment prior to deathAlzheimer's
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Alzheimer's
70
No treatment
Your Mother's Mother
Question Response
Current age or age at death 76
Living / DeadDead
Cause of death and any treatment prior to deathCOVID-19
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
 
No other diagnosed health problems at time of death
Your Mother's Sisters 1
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 2
Question Response
Current age or age at death 55
Living / DeadDead
Cause of death and any treatment prior to deathBreast Cancer, chemotherapy
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
 
No other diagnosed health problems at time of death
Your Mother's Sisters 3
Question Response
Current age or age at death 53
Living / DeadDead
Cause of death and any treatment prior to deathLung Cancer (heavy smoker)
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
 
No other diagnosed health problems at time of death
Your Mother'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 Mother's Brothers 2
Question Response
Current age or age at death 52
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 88
Living / DeadDead
Cause of death and any treatment prior to deathOld Age (specific cause unknown)
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
 
No known health problems at time of death
Your Father'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 Father's Brothers 1
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 Father's Brothers 2
Question Response
Current age or age at death 45
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy