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

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 lbs9
Birth weight ozs2
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 OriginsPolish
Mother's Mother Ethnic OriginsEnglish
Father's Father Ethnic OriginsEnglish
Father's Mother Ethnic OriginGerman
Is anyone in your family of Ashkenazai Jewish Heritage?No
If yes, who?N/A
Question Response
Current age or age at death 50
Living / DeadLiving
Cause of death and any treatment prior to deathN/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
Question Response
Current age or age at death 49
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Question Response
Current age or age at death 22
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Question Response
Current age or age at death 80
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
 
Gallbladder removed, Age 75
Question Response
Current age or age at death 77
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Breast cancer
70
Mastectomy
Question Response
Current age or age at death 54
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Question Response
Current age or age at death 70
Living / DeadDead
Cause of death and any treatment prior to deathMelanoma 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
Question Response
Current age or age at death 76
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Question Response
Current age or age at death 54
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy