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:		Wisdom teeth removal - 24
Hospitalization other than surgery:
Age & type of illness:		N/A
Have you ever had any broken bones?
If yes, please give age and description:		Yes - Broken collarbone at age 3 due to 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: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:Multi-vitamin and probiotic - Daily; General health
Do you wear glasses or contact lenses?
Are you near or far-sighted?		Yes - Near-sighted, 1.25/.75
Birth weight lbs8
Birth weight ozs8
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, causes itchy eyes and runny nose, treated with over the counter medication
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 History
See list of questions asked here

Mother's Father Ethnic OriginsMexican
Mother's Mother Ethnic OriginsMexican
Father's Father Ethnic OriginsMexican
Father's Mother Ethnic OriginMexican
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 47
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 48
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Disease
Age Diagnosed
Treatment For Condition
High blood pressure
30
Medication
High cholesterol
30
Medication
Sisters
Your Sister 1
Question Response
Current age or age at death 24
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 22
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 81
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Diabetes mellitus requiring insulin therapy
70
Insulin
Your Mother's Mother
Question Response
Current age or age at death 76
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
 
Lactose intolerance, diagnosed at age 60, treated with diet
Your Mother's Sisters 1
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 Mother's Sisters 2
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 Sisters 3
Question Response
Current age or age at death 54
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Your Mother's Sisters 4
Question Response
Current age or age at death 52
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 51
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 46
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 38
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 70
Living / DeadDead
Cause of death and any treatment prior to deathSepsis
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Colon cancer
67
Chemotherapy and radiation
Other
 
Sepsis at age 70, no treatment
Your Father's Mother
Question Response
Current age or age at death 68
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Disease
Age Diagnosed
Treatment For Condition
High blood pressure
50
Medication
Your Father's Sisters 1
Question Response
Current age or age at death 47
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 45
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 39
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Your Father's Sisters 4
Question Response
Current age or age at death 37
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 41
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 35
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Your Father's Brothers 3
Question Response
Current age or age at death 33
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy