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: | Frequently - Two or three beers or glasses of wine on Friday nights after work (36oz. of beer or 15oz. of wine or a mixture) |
| 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? | Yes |
| 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: | Mole removal - Age 5, parents were worried it was precancerous but it was benign |
| 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: | Marijuana, Alcohol - Once a month; One night; Recreational |
| 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 | 4 |
| Birth weight ozs | 11 |
| Recent weight loss or gain? # of lbs and reason: | No |
| Allergies (medicines, food, pollens)? If yes, please list substance and reaction caused: | Yes - Bee stings cause large local swelling, penicillin causes hives |
| 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 HistorySee list of questions asked here
| Mother's Father Ethnic Origins | German |
| Mother's Mother Ethnic Origins | Polish |
| Father's Father Ethnic Origins | Russian |
| Father's Mother Ethnic Origin | Russian |
| Is anyone in your family of Ashkenazai Jewish Heritage? | Yes |
| If yes, who? | All grandparents |
Your Mother
| Question | Response |
| Current age or age at death | 61 |
| 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 | 65 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Irritable Bowel Syndrome
55
Diet controlled
Your Mother's Father
| Question | Response |
| Current age or age at death | 85 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Parkinson’s Disease |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Heart attack
65
Four in total (at ages 55, 57, 61, 65), treated with hospitalization each time
Parkinson's disease
75
Medication and physical therapy
Your Mother's Mother
| Question | Response |
| Current age or age at death | 87 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Stroke, physical therapy |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Stroke
82
Physical therapy
Leukemia
68
Medication
Your Mother's Brothers 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 Brothers 2
| 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
Your Father's Father
| Question | Response |
| Current age or age at death | 82 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Testicular Cancer (smoker), chemotherapy |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Testicular Cancer
77
Chemotherapy
Your Father's Mother
| Question | Response |
| Current age or age at death | 79 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Dementia |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Diabetes mellitus requiring insulin therapy
55
Insulin
Dementia or degenerative disorders
77
Medication
Alzheimer's
79
None
Your Father's Sisters 1
| Question | Response |
| Current age or age at death | 61 |
| 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 | 57 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Your Father's Brothers 2
| Question | Response |
| Current age or age at death | 40 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy