Personal Behavior History

Question Response
Current alcohol use:
If yes, oz./week and type of alcohol:		Rarely - 8 oz./week of 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 Extraction - Age 25
Hospitalization other than surgery:
Age & type of illness:		Broken Arm - Age 15, Fell
Have you ever had any broken bones?
If yes, please give age and description:		Yes - Left Arm, Age 15, Happened due to fall on my left side
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:Amoxicillin-Pot Clavulanate 875-125 MG - Antibiotic 2 tablet per day; 10 days; Throat congestion
List all current medication or treatments (include vitamins, aspirin, antacids, laxatives, herbal, sports supplements, etc.) Include drug, frequency and duration taken, and reason:Whey protein - 30g per day; 2 years; Sport Supplemental
Do you wear glasses or contact lenses?
Are you near or far-sighted?		No
Birth weight lbs6
Birth weight ozs7
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?1
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 OriginsIranian
Mother's Mother Ethnic OriginsIranian
Father's Father Ethnic OriginsIranian
Father's Mother Ethnic OriginIranian
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 53
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 26
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 73
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Disease
Age Diagnosed
Treatment For Condition
High cholesterol
68
Single Bypass Surgery
Your Mother's Mother
Question Response
Current age or age at death 49
Living / DeadDead
Cause of death and any treatment prior to deathExcess fluid in brain (Hydrocephalus)
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Early death (less than age 50)
49
Excess fluid in brain (Hydrocephalus), No treatment
Your Mother's Sisters 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 Sisters 2
Question Response
Current age or age at death 42
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Your Mother's Sisters 3
Question Response
Current age or age at death 32
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 51
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 6
Living / DeadDead
Cause of death and any treatment prior to deathAccidental Death (Electrocution)
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Early death (less than age 50)
6
Accidental Death, Electrocution
Your Father's Father
Question Response
Current age or age at death 80
Living / DeadDead
Cause of death and any treatment prior to deathNatural Causes
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Diabetes mellitus requiring insulin therapy
70
Insulin
Your Father's Mother
Question Response
Current age or age at death 85
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Stroke
80
Physical Therapy
Your Father's Sisters 1
Question Response
Current age or age at death 65
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 60
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 57
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 50
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 23
Living / DeadDead
Cause of death and any treatment prior to deathDied in Combat
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Early death (less than age 50)
23
Died in Combat, no treatment needed