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 - Bourbon 0.25 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:		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:		N/A - N/A
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 - Once every three months; Sporadically on social occasions; Recreational Use
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?		Yes - Near-sighted, 20/300
Birth weight lbs7
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?1
Have you ever had a tattoo?Yes - 1: left ankle
Have you ever had your ear(s) or body pierced?Yes - 2: both earlobes

Family Medical History
See list of questions asked here

Mother's Father Ethnic OriginsWelsh
Mother's Mother Ethnic OriginsFilipino
Father's Father Ethnic OriginsFilipino
Father's Mother Ethnic OriginFilipino
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 / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Your Father
Question Response
Current age or age at death 63
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Heart attack
60
Diet Management
Brothers
Your Brother 1
Question Response
Current age or age at death 41
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 33
Living / DeadDead
Cause of death and any treatment prior to deathSepsis
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Early death (less than age 50)
33
Sepsis, hospitalized, medication
Sisters
Your Sister 1
Question Response
Current age or age at death 36
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 27
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Your Mother's Father
Question Response
Current age or age at death 83
Living / DeadDead
Cause of death and any treatment prior to deathNatural Causes
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
 
No other diagnosed health problems at time of death
Your Mother's Mother
Question Response
Current age or age at death 86
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Your Mother's Brothers 1
Question Response
Current age or age at death 57
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Your Mother's Brothers 2
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 Mother's Brothers 3
Question Response
Current age or age at death 50
Living / DeadDead
Cause of death and any treatment prior to deathDrug Use (No contact)
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
 
No Contact, No known diagnosed health problems at time of death
Your Father's Father
Question Response
Current age or age at death 89
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Your Father's Mother
Question Response
Current age or age at death 82
Living / DeadDead
Cause of death and any treatment prior to deathCOVID-19
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 65
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 63
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Your Father's Sisters 3
Question Response
Current age or age at death 58
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 61
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy