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: | Wisdom Teeth Extraction; Tonsils Removed - Age 19, impacted; Age 22 |
| Hospitalization other than surgery: Age & type of illness: | Microdiscectomy - Age 38, sports injury, herniated discs |
| Have you ever had any broken bones? If yes, please give age and description: | Yes - Age 27, Left ankle, basketball injury |
| 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: | Advil - As needed; As needed; Back pain from lifting heavy weights |
| List all current medication or treatments (include vitamins, aspirin, antacids, laxatives, herbal, sports supplements, etc.) Include drug, frequency and duration taken, and reason: | Vitamin C, Fish Oils Omega 3, Plant based protein - Weekly ; 5 years; General Health |
| Do you wear glasses or contact lenses? Are you near or far-sighted? | Yes - Near-sighted, 20/40 |
| Birth weight lbs | 7 |
| Birth weight ozs | 3 |
| Recent weight loss or gain? # of lbs and reason: | No |
| Allergies (medicines, food, pollens)? If yes, please list substance and reaction caused: | Yes - Cats and Tree pollen, sneezing and itchy eyes |
| How many sexual partners do you currently have? | 0 |
| Have you ever had a tattoo? | No |
| Have you ever had your ear(s) or body pierced? | Yes - 2003 Left ear small earring. Hole is gone. Haven’t had it since 2014. |
Family Medical HistorySee list of questions asked here
| Mother's Father Ethnic Origins | Italian |
| Mother's Mother Ethnic Origins | 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 | 66 |
| 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 | 68 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Brothers
Your Brother 1
| Question | Response |
| Current age or age at death | 35 |
| 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 | 61 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Lung Cancer (Smoker) |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Lung cancer
57
No treatment
Your Mother's Mother
| Question | Response |
| Current age or age at death | 59 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Brain aneurism, surgery complication |
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 | 76 |
| 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 | 74 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Diabetes, no treatment |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Diabetes mellitus not requiring insulin therapy
64
No treatment
Your Mother's Brothers 2
| Question | Response |
| Current age or age at death | 73 |
| 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 | 71 |
| 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 | 75 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Liver Cancer |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Liver Cancer
74
No treatment
Your Father's Mother
| Question | Response |
| Current age or age at death | 83 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Old age |
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 | 74 |
| 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 | 73 |
| 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 | 62 |
| 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 | 64 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy