Personal Behavior History

Question Response
Current alcohol use:
If yes, oz./week and type of alcohol:
Frequently - Wine 10-15oz.
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

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:
Achilles tendon repair - Age 20, soccer injury
Hospitalization other than surgery:
Age & type of illness:
None - None
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:N/A - N/A; N/A; N/A
Do you wear glasses or contact lenses?
Are you near or far-sighted?
Yes - Near-sighted, OD: -0.25 OS: -0.25 -0.75 045
Birth weight lbs6
Birth weight ozs8
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?Yes - 2019 Ear

Family Medical History
See list of questions asked here

Mother's Father Ethnic OriginsLiberian
Mother's Mother Ethnic OriginsLiberian
Father's Father Ethnic OriginsLiberian
Father's Mother Ethnic OriginLiberian
Is anyone in your family of Ashkenazai Jewish Heritage?No
If yes, who?N/A
Question Response
Current age or age at death 60
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Question Response
Current age or age at death 57
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Question Response
Current age or age at death 33
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Question Response
Current age or age at death 18
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Question Response
Current age or age at death 19
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Question Response
Current age or age at death 84
Living / DeadDead
Cause of death and any treatment prior to deathPneumonia
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
 
No other diagnosed health problems at time of death
Question Response
Current age or age at death 79
Living / DeadDead
Cause of death and any treatment prior to deathPneumonia
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
 
No other diagnosed health problems at time of death
Question Response
Current age or age at death 53
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Question Response
Current age or age at death 33
Living / DeadDead
Cause of death and any treatment prior to deathDrowning
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
 
No diagnosed health problems at time of death
Question Response
Current age or age at death 80
Living / DeadDead
Cause of death and any treatment prior to deathSpecific cause of death unknown (no contact)
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
 
No known diagnosed health problems
Question Response
Current age or age at death 76
Living / DeadDead
Cause of death and any treatment prior to deathSpecific cause of death unknown (no contact)
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
 
No known diagnosed health problems