This donor is a healthy carrier for a genetic disease.
Please see his Genetic Testing Summary and Acknowledgment of Genetic Risk for details

Personal Behavior History

Question Response
Current alcohol use:
If yes, oz./week and type of alcohol:		Rarely - 12oz. beer a couple times 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:		Wisdom teeth extraction - Age 29
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:Marijuana - Rare; Isolated occasions, like on a holiday; Recreational
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, 20/30
Birth weight lbs9
Birth weight ozs3
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?Yes - 1, Left calf
Have you ever had your ear(s) or body pierced?No

Family Medical History
See list of questions asked here

Mother's Father Ethnic OriginsNorwegian
Mother's Mother Ethnic OriginsGerman-Czech
Father's Father Ethnic OriginsGerman
Father's Mother Ethnic OriginNorwegian
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 65
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 62
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 45
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Your Brother 2
Question Response
Current age or age at death 38
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
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
Sons
Your Son 1
Question Response
Current age or age at death 12
Living / DeadLiving
Health Problems
Healthy
Your Son 2
Question Response
Current age or age at death 6
Living / DeadLiving
Health Problems
Healthy
Daughters
Your Daughter 1
Question Response
Current age or age at death 9
Living / DeadLiving
Health Problems
Healthy
Your Mother's Father
Question Response
Current age or age at death 76
Living / DeadDead
Cause of death and any treatment prior to deathLung Cancer (smoker)
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Lung cancer
75
Chemotherapy
Your Mother's Mother
Question Response
Current age or age at death 92
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 70
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 67
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Your Mother's Brothers 3
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 Mother's Brothers 4
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 Father
Question Response
Current age or age at death 80
Living / DeadDead
Cause of death and any treatment prior to deathCoronary Artery Disease (smoker)
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other heart disease
75
Coronary Artery Disease, no treatment
Your Father's Mother
Question Response
Current age or age at death 89
Living / DeadDead
Cause of death and any treatment prior to deathInfection believed to be Pneumonia
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 59
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 77
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 73
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Your Father's Brothers 3
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 Father's Brothers 4
Question Response
Current age or age at death 65
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy