Personal Behavior History
Donor Sexual History
Donor Genetic History
Donor Medical History
Family Medical HistoryThis donor is a healthy carrier for a genetic disease.
Please see his Genetic Testing Summary and Acknowledgment of Genetic Risk for details
Please see his Genetic Testing Summary and Acknowledgment of Genetic Risk for details
Updated 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: | 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: | 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: | Multivitamin, Vitamin B complex, Fish Oil, Vitamin E, Creatine, Cranberry, Magnesium complex, Potassium - Daily; 10 years; Regular daily life maintenance |
| List all current medication or treatments (include vitamins, aspirin, antacids, laxatives, herbal, sports supplements, etc.) Include drug, frequency and duration taken, and reason: | Metamucil - Every few days; Many years; Just to stay regular |
| Do you wear glasses or contact lenses? Are you near or far-sighted? | Yes - Near-sighted, R: -1.50 -0.25 110 L: -1.50 -0.25 035 |
| Birth weight lbs | 10 |
| Birth weight ozs | 8 |
| Recent weight loss or gain? # of lbs and reason: | No |
| Allergies (medicines, food, pollens)? If yes, please list substance and reaction caused: | Yes - Ciprofloxacin, tendonitis (rare side effect of drug class Fluoroquinolones) |
| How many sexual partners do you currently have? | 1 |
| Have you ever had a tattoo? | Yes - 4: left pectoral, right pectoral, left abdomen, right abdomen |
| Have you ever had your ear(s) or body pierced? | No |
Family Medical HistorySee list of questions asked here
| Mother's Father Ethnic Origins | Costa Rican |
| Mother's Mother Ethnic Origins | Costa Rican |
| Father's Father Ethnic Origins | African American |
| Father's Mother Ethnic Origin | African American |
| 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 | 61 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Gallstones
60
Gallbladder removed
Macular Degeneration
57
OTC vitamins
Your Father
| Question | Response |
| Current age or age at death | 88 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Old Age (specific cause undetermined) |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Heart attack
70
Unknown
High blood pressure
65
Medication
Brothers
Your Brother 1
| Question | Response |
| Current age or age at death | 38 |
| 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 | 70 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Stroke |
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 | 88 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
High blood pressure
50
Beta Blockers
Diabetes mellitus requiring insulin therapy
50
Insulin
Your Mother'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 Mother's Sisters 2
| 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
Hay fever/Seasonal Allergies/Allergic Rhinitis
25
Antihistamines
Attention Deficit Hyperactivity Disorder (ADHD)
35
Adderall
Your Mother's Brothers 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 Mother's Brothers 2
| Question | Response |
| Current age or age at death | 60 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Meningitis |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
High blood pressure
40
Beta Blockers
Obesity
40
None
Your Father's Father
| Question | Response |
| Current age or age at death | 90 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Old Age (specific cause unknown) |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
No known diagnosed health problems at time of death
Your Father's Mother
| Question | Response |
| Current age or age at death | 92 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Old Age (specific cause unknown) |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
No known diagnosed health problems at time of death
Your Father's Sisters 1
| Question | Response |
| Current age or age at death | 90 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Old Age (specific cause unknown) |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
No known diagnosed health problems at time of death
Your Father's Sisters 2
| Question | Response |
| Current age or age at death | 80 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Old Age (specific cause unknown) |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
No known diagnosed health problems at time of death
Your Father's Brothers 1
| Question | Response |
| Current age or age at death | 90 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Old Age (specific cause unknown) |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
No known diagnosed health problems at time of death
Your Father's Brothers 2
| Question | Response |
| Current age or age at death | 80 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Old Age (specific cause unknown) |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
No known diagnosed health problems at time of death