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 - Beer 36 oz./week |
| 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: | Yes - I had rhotacism and a lisp until kindergarten. |
| 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: | Tonsillectomy; Wisdom teeth removed - Age 10, Tonsilitis; Age 18 |
| Hospitalization other than surgery: Age & type of illness: | Torn meniscus - Age 13, Torn meniscus, received brace, crutches, and underwent physical therapy |
| 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: | Amphetamine Salts - Daily; 11 months; ADHD (adult onset) |
| List all current medication or treatments (include vitamins, aspirin, antacids, laxatives, herbal, sports supplements, etc.) Include drug, frequency and duration taken, and reason: | Amphetamine Salts - Daily; 11 months; ADHD (adult onset) |
| Do you wear glasses or contact lenses? Are you near or far-sighted? | Yes - Near-sighted, 20/80 |
| Birth weight lbs | 6 |
| Birth weight ozs | 3 |
| 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? | 1 |
| Have you ever had a tattoo? | Yes - 5, 2 right arm, 1 left arm, 1 back, 1 chest |
| 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 | Irish-Scottish |
| Father's Father Ethnic Origins | Polish (Jewish) |
| Father's Mother Ethnic Origin | Russian (Jewish) |
| Is anyone in your family of Ashkenazai Jewish Heritage? | Yes |
| If yes, who? | Father |
Your Mother
| Question | Response |
| Current age or age at death | 56 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Brain Cancer, Chemotherapy and Radiation |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Any cancer not mentioned above
34
Brain Cancer, Chemotherapy and Radiation
Your Father
| Question | Response |
| Current age or age at death | 77 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
High blood pressure
60
Medications
Kidney Stones
68
Kidney Stone Removal (reoccurrence at age 76)
Other disease of the kidney, urinary tract, urethra, bladder, ureter
12
Kidney Disease, Kidney Removal
Other
Age 66, received Pacemaker
Brothers
Your Brother 1
| Question | Response |
| Current age or age at death | 44 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Your Mother's Father
| Question | Response |
| Current age or age at death | 68 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Lung Cancer (smoker) |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Lung cancer
66
Chemotherapy and Radiation (Smoker)
Your Mother's Mother
| Question | Response |
| Current age or age at death | 97 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Multiple Organ Failure |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
No other diagnosed health problems at time of death
Your Mother's Brothers 1
| Question | Response |
| Current age or age at death | 79 |
| 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 | 99 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Multiple Organ Failure |
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 | 88 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Multiple Organ Failure |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
No other diagnosed health problems at time of death
Your Father's Sisters 1
| Question | Response |
| Current age or age at death | 76 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
Age 75, Ozempic for weight loss