Personal Behavior History
Donor Sexual History
Donor Genetic History
Donor Medical History
Family Medical HistoryThis donor is a healthy carrier for a genetic disease.
Please see his Genetic Testing Summary and Acknowledgment of Genetic Risk for details
Please see his Genetic Testing Summary and Acknowledgment of Genetic Risk for details
Personal Behavior History
| Question | Response |
| Current alcohol use: If yes, oz./week and type of alcohol: | Occasionally - 12 oz. Beer |
| 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: | Back surgery - Age 32, due to pinched nerve |
| Hospitalization other than surgery: Age & type of illness: | None - None |
| Have you ever had any broken bones? If yes, please give age and description: | Yes - Age 22, ankle playing softball; Age 14, collar bone playing hockey |
| 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: | None - None; None; None |
| List all current medication or treatments (include vitamins, aspirin, antacids, laxatives, herbal, sports supplements, etc.) Include drug, frequency and duration taken, and reason: | None - None; None; None |
| Do you wear glasses or contact lenses? Are you near or far-sighted? | No |
| Birth weight lbs | 10 |
| Birth weight ozs | 5 |
| 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 HistorySee list of questions asked here
| Mother's Father Ethnic Origins | Irish |
| Mother's Mother Ethnic Origins | Polish |
| Father's Father Ethnic Origins | German |
| Father's Mother Ethnic Origin | German |
| 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 | 69 |
| 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 | 72 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Sisters
Your Sister 1
| Question | Response |
| Current age or age at death | 42 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Any cancer not mentioned above
21
Hodgkin's Lymphoma, received radiation and is in remission
Your Mother's Father
| Question | Response |
| Current age or age at death | 63 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Heart Attack |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
High blood pressure
60
Medication
Your Mother's Mother
| Question | Response |
| Current age or age at death | 87 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Bile Duct Cancer |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Any other cancer/problem of digestive system
83
Bile Duct Cancer, no treatment
Your Mother's Brothers 1
| 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
Your Mother's Brothers 2
| Question | Response |
| Current age or age at death | 66 |
| 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 | 61 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Throat cancer (smoker) |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Throat Cancer
60
Radiation
Your Father's Mother
| Question | Response |
| Current age or age at death | 94 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Broken Hip and health quickly declined |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
No other diagnosed health problems at time of death
Your Father's Sisters 1
| Question | Response |
| Current age or age at death | 74 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Your Father's Brothers 1
| Question | Response |
| Current age or age at death | 69 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy