Personal Behavior History
Question | Response |
Current alcohol use: If yes, oz./week and type of alcohol: | Rarely - 12oz. Beer twice per month |
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: | N/A - N/A |
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: | 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, 20/450 |
Birth weight lbs | 6 |
Birth weight ozs | 5 |
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? | Yes - 7, 2 Left hand, 3 left arm, 1 neck, 1 chest |
Have you ever had your ear(s) or body pierced? | Yes - 2, Both ears |
Family Medical HistorySee list of questions asked here
Mother's Father Ethnic Origins | Mexican |
Mother's Mother Ethnic Origins | Mexican |
Father's Father Ethnic Origins | Mexican |
Father's Mother Ethnic Origin | Mexican |
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
Healthy
Your Father
Question | Response |
Current age or age at death | 55 |
Living / Dead | Living |
Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Sisters
Your Sister 1
Question | Response |
Current age or age at death | 28 |
Living / Dead | Living |
Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Your Sister 2
Question | Response |
Current age or age at death | 18 |
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 | Dead |
Cause of death and any treatment prior to death | Heart failure, passed in sleep |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
No other diagnosed health problems at time of death
Your Mother's Mother
Question | Response |
Current age or age at death | 96 |
Living / Dead | Dead |
Cause of death and any treatment prior to death | Heart failure, passed in sleep |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
No other diagnosed health problems at time of death
Your Mother's Sisters 1
Question | Response |
Current age or age at death | 66 |
Living / Dead | Dead |
Cause of death and any treatment prior to death | Stomach Cancer, Chemotherapy |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Stomach Cancer
60
Chemotherapy
Your Mother's Sisters 2
Question | Response |
Current age or age at death | 58 |
Living / Dead | Living |
Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Your Mother's Sisters 3
Question | Response |
Current age or age at death | 46 |
Living / Dead | Living |
Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Your Mother's Brothers 1
Question | Response |
Current age or age at death | 69 |
Living / Dead | Living |
Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Your Mother's Brothers 2
Question | Response |
Current age or age at death | 67 |
Living / Dead | Living |
Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Your Mother's Brothers 3
Question | Response |
Current age or age at death | 55 |
Living / Dead | Living |
Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Your Mother's Brothers 4
Question | Response |
Current age or age at death | 53 |
Living / Dead | Living |
Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Your Mother's Brothers 5
Question | Response |
Current age or age at death | 52 |
Living / Dead | Living |
Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Your Mother's Brothers 6
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
Disease
Age Diagnosed
Treatment For Condition
Any cancer not mentioned above
46
Mouth Cancer, Chemotherapy (Smoker)
Your Mother's Brothers 7
Question | Response |
Current age or age at death | 47 |
Living / Dead | Living |
Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Your Mother's Brothers 8
Question | Response |
Current age or age at death | 35 |
Living / Dead | Dead |
Cause of death and any treatment prior to death | Gunshot wound, no treatment |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Early death (less than age 50)
35
Gunshot wound, no other diagnosed health problems at time of death
Your Father's Father
Question | Response |
Current age or age at death | 80 |
Living / Dead | Dead |
Cause of death and any treatment prior to death | Heart failure, passed in sleep |
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 | 97 |
Living / Dead | Dead |
Cause of death and any treatment prior to death | Heart failure, passed in sleep |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
No other diagnosed health problems at time of death
Your Father's Sisters 1
Question | Response |
Current age or age at death | 65 |
Living / Dead | Living |
Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Your Father's Sisters 2
Question | Response |
Current age or age at death | 59 |
Living / Dead | Living |
Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Your Father's Sisters 3
Question | Response |
Current age or age at death | 56 |
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 | 75 |
Living / Dead | Dead |
Cause of death and any treatment prior to death | Heart failure, passed in sleep |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
No other diagnosed health problems at time of death
Your Father's Brothers 2
Question | Response |
Current age or age at death | 71 |
Living / Dead | Living |
Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Your Father's Brothers 3
Question | Response |
Current age or age at death | 70 |
Living / Dead | Living |
Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Your Father's Brothers 4
Question | Response |
Current age or age at death | 67 |
Living / Dead | Living |
Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Your Father's Brothers 5
Question | Response |
Current age or age at death | 62 |
Living / Dead | Living |
Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Your Father's Brothers 6
Question | Response |
Current age or age at death | 58 |
Living / Dead | Living |
Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Your Father's Brothers 7
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
Disease
Age Diagnosed
Treatment For Condition
Prostate cancer
53
Chemotherapy and Radiation
Your Father's Brothers 8
Question | Response |
Current age or age at death | 46 |
Living / Dead | Dead |
Cause of death and any treatment prior to death | Alcohol Poisoning, no treatment |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Drug abuse, misuse, or addiction
46
No treatment
Early death (less than age 50)
46
Alcohol Poisoning
Your Father's Brothers 9
Question | Response |
Current age or age at death | 44 |
Living / Dead | Living |
Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy