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 removal - Age 14 |
| 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: | Yes - Age 17, left thumb, lacrosse 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: | 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 lbs | 7 |
| Birth weight ozs | 7 |
| Recent weight loss or gain? # of lbs and reason: | No |
| Allergies (medicines, food, pollens)? If yes, please list substance and reaction caused: | Yes - Poison ivy, rash/boils |
| 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? | No |
Family Medical HistorySee list of questions asked here
| Mother's Father Ethnic Origins | German |
| Mother's Mother Ethnic Origins | English-Scottish-Irish |
| Father's Father Ethnic Origins | English-Norwegian |
| Father's Mother Ethnic Origin | Scottish-Irish |
| 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 | 59 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Osteoarthritis
50
Supplements
Other
Age 9-10 diagnosed with Factor V Leiden, no medication
Your Father
| Question | Response |
| Current age or age at death | 57 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other heart disease
54
Aortic valve stenosis, treated with transcatheter aortic valve replacement
High blood pressure
50
Medication
High cholesterol
50
Medication
Diabetes mellitus requiring insulin therapy
38
Insulin
Other disease of the kidney, urinary tract, urethra, bladder, ureter
51
Kidney failure related to diabetes, takes medication
Any other sight/sound/smell disorder
52
Diabetes-related vision problems, takes medication
Other
Diagnosed at age 42 with peripheral neuropathy, takes medication
Brothers
Your Brother 1
| Question | Response |
| Current age or age at death | 18 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Car Accident, no treatment |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Eczema
16
Occasionally used steroids
Early death (less than age 50)
18
Accidental death (car accident)
Your Mother's Father
| Question | Response |
| Current age or age at death | 80 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Lung cancer (smoker), no treatment |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Lung cancer
68
No treatment
Your Mother's Mother
| Question | Response |
| Current age or age at death | 80 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Lung failure (smoker), no treatment |
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 | 70 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Ovarian cancer, chemotherapy |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Cancer of cervix, ovaries, or uterus
65
Ovarian cancer treated with chemotherapy
Your Mother's Brothers 1
| Question | Response |
| Current age or age at death | 70 |
| 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 | 80 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Alzheimer's, Medication |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Alzheimer's
60
Medication
Your Father's Mother
| Question | Response |
| Current age or age at death | 80 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Endocarditis, medication |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other heart disease
78
Heart failure, treated with surgery
Drug abuse, misuse, or addiction
50
Alcoholism, no treatment
Your Father's Sisters 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
Disease
Age Diagnosed
Treatment For Condition
Diabetes mellitus not requiring insulin therapy
30
No treatment
Your Father's Brothers 1
| Question | Response |
| Current age or age at death | 63 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Heart Valve Failure |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other heart disease
55
Heart valve replacement