Personal Behavior History
Donor Sexual History
Donor Genetic History
Donor Medical History
Family Medical HistoryUpdated medical information on the donor and his family (if applicable) will be included at the bottom of the Summary Profile
Personal Behavior History
| Question | Response |
| Current alcohol use: If yes, oz./week and type of alcohol: | Occasionally - 12oz. 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? | No - Staying up late to socialize |
| 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 tooth removal - Age 24, impacted teeth |
| Hospitalization other than surgery: Age & type of illness: | C. diff colitis infection - Age 19, bacterial infection of gut flora |
| Have you ever had any broken bones? If yes, please give age and description: | Yes - Age 22, right orbital bone, and nose bone. Both breaks from the same lifting accident. I dropped 200 lbs. on my face when bench pressing |
| Have you ever had any serious illnesses? If yes, please give age and description: | Yes - Lyme disease in 2016. I have no complications now and got over the disease in 2 months |
| 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: | THC - 3-5 times a week; Off and on for 4 years; To reduce stress and to ease physical pain |
| List all current medication or treatments (include vitamins, aspirin, antacids, laxatives, herbal, sports supplements, etc.) Include drug, frequency and duration taken, and reason: | Fish Oil, Greens Powder, Creatine, Multivitamin - Daily; Regularly for 7 years, Off and on for 2 years, Off and on for 7 years, Regularly for 7 years; General Health |
| Do you wear glasses or contact lenses? Are you near or far-sighted? | Yes - Near-sighted, -5.00/-5.00 |
| Birth weight lbs | 9 |
| Birth weight ozs | 0 |
| Recent weight loss or gain? # of lbs and reason: | No |
| Allergies (medicines, food, pollens)? If yes, please list substance and reaction caused: | Yes - Penicillin and amoxicillin , full body rash similar to hives |
| How many sexual partners do you currently have? | 0 |
| Have you ever had a tattoo? | Yes - 3, right leg, left forearm, left shoulder |
| Have you ever had your ear(s) or body pierced? | No |
Family Medical HistorySee list of questions asked here
| Mother's Father Ethnic Origins | German-Italian-English |
| Mother's Mother Ethnic Origins | Scottish-Irish-Italian |
| Father's Father Ethnic Origins | Italian |
| Father's Mother Ethnic Origin | Italian |
| 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 | 55 |
| 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 | 60 |
| 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 | 27 |
| 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 | 75 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Your Mother's Mother
| Question | Response |
| Current age or age at death | 74 |
| 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 | 50 |
| 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 | Kidney Disease, dialysis |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Progressive kidney disease
65
Dialysis
Your Father's Mother
| Question | Response |
| Current age or age at death | 50 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Breast Cancer |
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 | 58 |
| 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 | 54 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy