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:		Daily - Historically 100oz./week of beer or 20oz./week of brandy, though I haven't been drinking the last two months
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 16, routine procedure
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:N/A - N/A; N/A; N/A
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?		No
Birth weight lbs10
Birth weight ozs9
Recent weight loss or gain?
# of lbs and reason:		No
Allergies (medicines, food, pollens)?
If yes, please list substance and reaction caused:		Yes - Sulfa drugs cause a slight rash
How many sexual partners do you currently have?1
Have you ever had a tattoo?Yes - 1: right arm
Have you ever had your ear(s) or body pierced?No

Family Medical History
See list of questions asked here

Mother's Father Ethnic OriginsGerman
Mother's Mother Ethnic OriginsGerman
Father's Father Ethnic OriginsAfrican American
Father's Mother Ethnic OriginAfrican 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 70
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Disease
Age Diagnosed
Treatment For Condition
High blood pressure
70
Diet management
Eczema
36
None
Breast cancer
62
Chemotherapy and surgery
Your Father
Question Response
Current age or age at death 68
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Diabetes mellitus not requiring insulin therapy
68
Medication and diet controlled
Other
 
Had measles and encephalitis at age 8
Brothers
Your Brother 1
Question Response
Current age or age at death 35
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Psoriasis
25
Special Shampoo
Sons
Your Son 1
Question Response
Current age or age at death 3
Living / DeadLiving
Health Problems
Healthy
Daughters
Your Daughter 1
Question Response
Current age or age at death 2
Living / DeadLiving
Health Problems
Healthy
Your Mother's Father
Question Response
Current age or age at death 96
Living / DeadDead
Cause of death and any treatment prior to deathHeart Failure caused by COVID-19, hospitalization
Health Problems
Disease
Age Diagnosed
Treatment For Condition
High blood pressure
88
Statins
Ulcer of stomach/duodenum
48
Stopped Smoking
Your Mother's Mother
Question Response
Current age or age at death 86
Living / DeadDead
Cause of death and any treatment prior to deathHeart Disease and Dementia
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Miscarriages or stillborn
38
None
Dementia or degenerative disorders
81
Care facility
Eczema
50
None advised
Your Mother's Sisters 1
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 Mother's Sisters 2
Question Response
Current age or age at death 58
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Asthma
20
Inhaler
Your Mother's Sisters 3
Question Response
Current age or age at death 56
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Psoriasis
40
Medication
Your Mother's Brothers 1
Question Response
Current age or age at death 72
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Disease
Age Diagnosed
Treatment For Condition
High blood pressure
66
Medication
Asthma
35
Inhaler
Your Father's Father
Question Response
Current age or age at death 67
Living / DeadDead
Cause of death and any treatment prior to deathType I Diabetes (complications from amputation surgery)
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Diabetes mellitus requiring insulin therapy
50
Poorly managed, died shortly after amputation of all four limbs
Your Father's Mother
Question Response
Current age or age at death 64
Living / DeadDead
Cause of death and any treatment prior to deathLung Cancer and Pneumonia
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Lung cancer
64
Chemotherapy and radiation
Your Father's Brothers 1
Question Response
Current age or age at death 68
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy