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: | Occasionally - Whiskey and Gin 2-4 oz./week |
| 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: | Tonsils removed; Wisdom teeth removal; 3 mole biopsies - Age 5, inflammation; Age 27, recommendation; Ages 26, 29, and 31, precautionary melanoma screening (all benign) |
| Hospitalization other than surgery: Age & type of illness: | Hospitalized to reset the bone - Age 11, Bicycle accident |
| Have you ever had any broken bones? If yes, please give age and description: | Yes - Age 11, Broken arm, Bicycle crash |
| 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, D3, B12, omega fish oil, ibuprofen - Daily; A few years; Maintain optimal health, for pain after working out |
| List all current medication or treatments (include vitamins, aspirin, antacids, laxatives, herbal, sports supplements, etc.) Include drug, frequency and duration taken, and reason: | Multivitamin, D3, B12, omega fish oil - Daily; 12 months; Maintain optimal health |
| Do you wear glasses or contact lenses? Are you near or far-sighted? | Yes - Near-sighted, -0.25/-0.25 |
| Birth weight lbs | 7 |
| Birth weight ozs | 14 |
| 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 - 2, 1 back, 1 left side |
| 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-Mexican |
| Mother's Mother Ethnic Origins | Norwegian |
| Father's Father Ethnic Origins | Irish-Norwegian-Scottish |
| Father's Mother Ethnic Origin | Irish-French-Scottish |
| 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 | 54 |
| 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 | 54 |
| 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 | 34 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Daughters
Your Daughter 1
| Question | Response |
| Current age or age at death | 1 |
| Living / Dead | Living |
Health Problems
Healthy
Your Mother's Father
| Question | Response |
| Current age or age at death | 87 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Natural Causes |
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 | 73 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Diabetes Type II, Insulin |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Heart attack
69
No treatment
High blood pressure
50
Tablets
Diabetes mellitus requiring insulin therapy
40
Type II, Insulin
Your Mother'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 Mother's Sisters 2
| 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 Sisters 3
| Question | Response |
| Current age or age at death | 35 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Accident, Shot, no treatment |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
No other diagnosed health problems at time of death
Your Mother's Sisters 4
| Question | Response |
| Current age or age at death | 28 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Accident, blunt force trauma, no treatment |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
No other diagnosed health problems at time of death
Your Father's Father
| 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 Mother
| Question | Response |
| Current age or age at death | 71 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Staph Infection, Antibiotics |
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 | 52 |
| 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 | 56 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy