Personal Behavior History

Question Response
Current alcohol use:
If yes, oz./week and type of alcohol:		Occasionally - 12oz. 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:		Wisdom teeth removed - Age 16
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:		Yes - Age 12, nose, playing baseball; Age 17, wrist, playing football; Age 18, thumb, fell while running
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:Multivitamin, Biotin - Daily; 7 years; General Health
Do you wear glasses or contact lenses?
Are you near or far-sighted?		No
Birth weight lbs8
Birth weight ozs1
Recent weight loss or gain?
# of lbs and reason:		No
Allergies (medicines, food, pollens)?
If yes, please list substance and reaction caused:		Yes - Ciprofloxacin, liver inflammation
How many sexual partners do you currently have?1
Have you ever had a tattoo?Yes - 1 on my left forearm
Have you ever had your ear(s) or body pierced?Yes - Left and right ears

Family Medical History
See list of questions asked here

Mother's Father Ethnic OriginsIrish
Mother's Mother Ethnic OriginsIrish
Father's Father Ethnic OriginsRussian
Father's Mother Ethnic OriginRussian
Is anyone in your family of Ashkenazai Jewish Heritage?Yes
If yes, who?Father's side of the family
Your Mother
Question Response
Current age or age at death 72
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Disease
Age Diagnosed
Treatment For Condition
High blood pressure
40
Medication
Your Father
Question Response
Current age or age at death 71
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Asthma
12
Inhaler
Sisters
Your Sister 1
Question Response
Current age or age at death 41
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 38
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Asthma
12
Inhaler
Your Mother's Father
Question Response
Current age or age at death 86
Living / DeadDead
Cause of death and any treatment prior to deathNatural Causes (specific cause unknown)
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
 
No diagnosed health problems at time of death
Your Mother's Mother
Question Response
Current age or age at death 82
Living / DeadDead
Cause of death and any treatment prior to deathBreast Cancer
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Breast cancer
78
Chemotherapy
Your Mother's Sisters 1
Question Response
Current age or age at death 76
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 68
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 66
Living / DeadDead
Cause of death and any treatment prior to deathHeart Attack
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
 
No other diagnosed health problems at time of death
Your Mother's Brothers 2
Question Response
Current age or age at death 65
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Disease
Age Diagnosed
Treatment For Condition
High blood pressure
40
Medication
Your Father's Father
Question Response
Current age or age at death 40
Living / DeadDead
Cause of death and any treatment prior to deathDrowning 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 84
Living / DeadDead
Cause of death and any treatment prior to deathDementia
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Dementia or degenerative disorders
81
Nursing care
Your Father's Sisters 1
Question Response
Current age or age at death 74
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 50
Living / DeadDead
Cause of death and any treatment prior to deathLung Cancer (smoker)
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Lung cancer
48
No treatment