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:		Rarely - 12oz. beer a couple times per month
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?No
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; Back Surgery - Age 13, all 4 removed; Age 22, to fix a lower disc
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 lbs6
Birth weight ozs3
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?0
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 OriginsGerman-Swedish
Mother's Mother Ethnic OriginsEnglish-German
Father's Father Ethnic OriginsSweden
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 57
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
 
Varicose veins surgery and mesh for bladder surgery, both at age 50
Your Father
Question Response
Current age or age at death 60
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Brothers
Your Brother 1
Question Response
Current age or age at death 27
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 18
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Sisters
Your Sister 1
Question Response
Current age or age at death 25
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Your Sister 2
Question Response
Current age or age at death 20
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Your Sister 3
Question Response
Current age or age at death 16
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Daughters
Your Daughter 1
Question Response
Current age or age at death 13
Living / DeadLiving
Health Problems
Healthy
Your Mother's Father
Question Response
Current age or age at death 83
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Your Mother's Mother
Question Response
Current age or age at death 77
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
 
Age 20: Issues related to bad car accident
Your Mother's Sisters 1
Question Response
Current age or age at death 48
Living / DeadDead
Cause of death and any treatment prior to deathOverdose
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Diabetes mellitus not requiring insulin therapy
12
Type I, not managed with insulin due to lifestyle
Drug abuse, misuse, or addiction
48
None - Died; unknown age for start of addiction (long time issue)
Your Mother's Brothers 1
Question Response
Current age or age at death 45
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 80
Living / DeadDead
Cause of death and any treatment prior to deathLiver Failure (heavy smoker and drinker)
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
 
No other diagnosed health problems at time of death
Your Father's Mother
Question Response
Current age or age at death 68
Living / DeadDead
Cause of death and any treatment prior to deathStomach Cancer
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Stomach Cancer
66
Chemotherapy
Other
 
Heavy drinker and smoker
Your Father's Sisters 1
Question Response
Current age or age at death 55
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 63
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Your Father's Brothers 2
Question Response
Current age or age at death 53
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy