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: | Surgery to fix a distal radial fracture - Age 18, Fell backwards down some steps and broke my wrist, physical therapy |
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 18, Broken wrist, took a fall backwards down some stairs and it broke, physical therapy |
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: | Percocet, Tramadol, and Naproxen - Daily; 1 week, 2 weeks, 3 weeks; Percocet and Tramadol were both prescribed when I broke my wrist to reduce pain and the Naproxen was to reduce swelling |
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 - Far-Sighted, 2.0/ 2.0 |
Birth weight lbs | 9 |
Birth weight ozs | 2 |
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 HistorySee list of questions asked here
Mother's Father Ethnic Origins | Polish |
Mother's Mother Ethnic Origins | English |
Father's Father Ethnic Origins | English |
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 | 50 |
Living / Dead | Living |
Cause of death and any treatment prior to death | N/A |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
Age 36, Age 45, Age 47, Surgery for herniated disc due to military duty, physical therapy
Your Father
Question | Response |
Current age or age at death | 49 |
Living / Dead | Living |
Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Brothers
Your Brother 1
Question | Response |
Current age or age at death | 22 |
Living / Dead | Living |
Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Your Mother's Father
Question | Response |
Current age or age at death | 80 |
Living / Dead | Living |
Cause of death and any treatment prior to death | N/A |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
Gallbladder removed, Age 75
Your Mother's Mother
Question | Response |
Current age or age at death | 77 |
Living / Dead | Living |
Cause of death and any treatment prior to death | N/A |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Breast cancer
70
Mastectomy
Your Mother's Brothers 1
Question | Response |
Current age or age at death | 54 |
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 | 70 |
Living / Dead | Dead |
Cause of death and any treatment prior to death | Melanoma metastasized and caused Leukemia, Age 70, Chemotherapy and removal of melanoma |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
No other diagnosed health problems at time of death
Your Father's Mother
Question | Response |
Current age or age at death | 76 |
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 | 54 |
Living / Dead | Living |
Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy