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:		Regularly - Typically either 1-2 12 oz. beers at a time or 1-2 4 oz. glasses of red wine at a time
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:		Yes - Mother's sister was born with congenital heart disease (hole in heart)

Donor Medical History

Question Response
List any operations:
Age & reason:		Lasik - Age 28 for vision correction
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 22, fifth metacarpal, boxer's fracture, a little rambunctious with friends
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, Allegra, Flonase, multivitamin, Zinc, Lycopene supplements - Allegra and Flonase Daily. Advil only as needed, daily for each vitamin/supplement; April-July or August during allergy season, one week for each vitamin/supplement; Seasonal allergies, to improve health
List all current medication or treatments (include vitamins, aspirin, antacids, laxatives, herbal, sports supplements, etc.) Include drug, frequency and duration taken, and reason:Allegra, multivitamin, Zinc - Daily, daily for each vitamin/supplement; April-July or August 2025, one week for vitamins/supplements; Seasonal allergies, improve health
Do you wear glasses or contact lenses?
Are you near or far-sighted?		Yes - Near-sighted, -2.25/-2.25
Birth weight lbs8
Birth weight ozs1
Recent weight loss or gain?
# of lbs and reason:		No
Allergies (medicines, food, pollens)?
If yes, please list substance and reaction caused:		Yes - Tree pollen, minor itchy throat, congestion, runny nose
How many sexual partners do you currently have?1
Have you ever had a tattoo?No
Have you ever had your ear(s) or body pierced?No

Family Medical History
See list of questions asked here

Mother's Father Ethnic OriginsFrench-German
Mother's Mother Ethnic OriginsGerman
Father's Father Ethnic OriginsGerman
Father's Mother Ethnic OriginGerman
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 / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Disease
Age Diagnosed
Treatment For Condition
High blood pressure
56
Olmesartan, 20mg
Kidney Stones
40
Waited to pass
Your Father
Question Response
Current age or age at death 71
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Parkinson's disease
68
Medication
Brothers
Your Brother 1
Question Response
Current age or age at death 38
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Your Brother 2
Question Response
Current age or age at death 31
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Sons
Your Son 1
Question Response
Current age or age at death 5
Living / DeadLiving
Health Problems
Healthy
Your Son 2
Question Response
Current age or age at death 1
Living / DeadLiving
Health Problems
Healthy
Daughters
Your Daughter 1
Question Response
Current age or age at death 1
Living / DeadLiving
Health Problems
Healthy
Your Mother's Father
Question Response
Current age or age at death 61
Living / DeadDead
Cause of death and any treatment prior to deathHeart Failure (smoker), no treatment
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Stroke
42
Unknown
Other
 
Diagnosed with high blood pressure, Type 2 Diabetes (insulin dependent), and transient ischemic attacks in his 40s (specific ages of diagnosis unknown).
Your Mother's Mother
Question Response
Current age or age at death 70
Living / DeadDead
Cause of death and any treatment prior to deathAdenocarcinoma
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Any cancer not mentioned above
68
Adenocarcinoma, no treatment
Your Mother's Sisters 1
Question Response
Current age or age at death 67
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 61
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Your Mother's Sisters 3
Question Response
Current age or age at death 59
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Congenital heart disease
 
Born with a hole in her heart, underwent open heart surgery after birth
Your Mother's Brothers 1
Question Response
Current age or age at death 69
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Your Father's Father
Question Response
Current age or age at death 92
Living / DeadDead
Cause of death and any treatment prior to deathHeart Failure, no treatment
Health Problems
Disease
Age Diagnosed
Treatment For Condition
High blood pressure
60
Medication
Your Father's Mother
Question Response
Current age or age at death 93
Living / DeadDead
Cause of death and any treatment prior to deathHeart Failure, no treatment
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Any other sight/sound/smell disorder
70
Cataracts treated with surgery
Your Father's Sisters 1
Question Response
Current age or age at death 73
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Your Father's Sisters 2
Question Response
Current age or age at death 64
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Your Father's Brothers 1
Question Response
Current age or age at death 78
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Disease
Age Diagnosed
Treatment For Condition
High blood pressure
60
Medication
Your Father's Brothers 2
Question Response
Current age or age at death 74
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Leukemia
65
Annual blood tests, no treatment
Your Father's Brothers 3
Question Response
Current age or age at death 66
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Prostate cancer
62
Surgery