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: | Never |
| 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: | Yes - Age 12, wrist, skating accident |
| 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: | Dayquil and Nyquil - As needed; As needed; Flu |
| 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 | 8 |
| Birth weight ozs | 7 |
| Recent weight loss or gain? # of lbs and reason: | No |
| Allergies (medicines, food, pollens)? If yes, please list substance and reaction caused: | Yes - Seasonal allergies, stuffy nose, itchy skin and puffy eyes |
| 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? | Yes - 2: left and right earlobes |
Family Medical HistorySee list of questions asked here
| Mother's Father Ethnic Origins | Haitian-Cuban |
| Mother's Mother Ethnic Origins | Haitian |
| Father's Father Ethnic Origins | Haitian |
| Father's Mother Ethnic Origin | Haitian-Cuban |
| 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 | 68 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Diabetes mellitus not requiring insulin therapy
50
Diet and lifestyle changes
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
Healthy
Brothers
Your Brother 1
| Question | Response |
| Current age or age at death | 33 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Your Brother 2
| Question | Response |
| Current age or age at death | 31 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Sisters
Your Sister 1
| Question | Response |
| Current age or age at death | 38 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Sons
Your Son 1
| Question | Response |
| Current age or age at death | 1 |
| Living / Dead | Living |
Health Problems
Healthy
Daughters
Your Daughter 1
| Question | Response |
| Current age or age at death | 3 |
| Living / Dead | Living |
Health Problems
Healthy
Your Mother's Father
| Question | Response |
| Current age or age at death | 101 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Old Age |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
No diagnosed health problems at time of death
Your Mother's Mother
| Question | Response |
| Current age or age at death | 92 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Accidental Fall |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Diabetes mellitus not requiring insulin therapy
90
Medication
Your Mother's Sisters 1
| Question | Response |
| Current age or age at death | 43 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Died during childbirth |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Early death (less than age 50)
43
Died during childbirth, no diagnosed health problems at time of death
Your Mother's Brothers 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
Healthy
Your Mother's Brothers 2
| Question | Response |
| Current age or age at death | 75 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Your Mother's Brothers 3
| Question | Response |
| Current age or age at death | 47 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Workplace Accident |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Early death (less than age 50)
47
Workplace accident, no diagnosed health problems at time of death
Your Father's Father
| Question | Response |
| Current age or age at death | 36 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Killed During Military Service |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Early death (less than age 50)
36
War casualty, no diagnosed health problems at time of death
Your Father's Mother
| Question | Response |
| Current age or age at death | 92 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Old Age |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
No diagnosed health problems at time of death
Your Father's Sisters 1
| Question | Response |
| Current age or age at death | 71 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Your Father's Sisters 2
| Question | Response |
| Current age or age at death | 69 |
| 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 | 65 |
| 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 | 36 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Murdered |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Early death (less than age 50)
36
Murdered, no diagnosed health problems at time of death