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:		None - None
Hospitalization other than surgery:
Age & type of illness:		None - None
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:		Yes - Thyroid cyst (benign) drainage at age 15, annual checkups since
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:Claritin - As needed for seasonal allergies; Daily as needed; Seasonal allergies
List all current medication or treatments (include vitamins, aspirin, antacids, laxatives, herbal, sports supplements, etc.) Include drug, frequency and duration taken, and reason:None - N/A; N/A; N/A
Do you wear glasses or contact lenses?
Are you near or far-sighted?		Yes - 20/650
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 (probably pollen), itchiness
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 OriginsChinese
Mother's Mother Ethnic OriginsChinese
Father's Father Ethnic OriginsChinese
Father's Mother Ethnic OriginChinese
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 49
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Diabetes mellitus not requiring insulin therapy
42
Change of diet
Your Father
Question Response
Current age or age at death 60
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Brothers
Your Brother 1
Question Response
Current age or age at death 20
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 8
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 68
Living / DeadDead
Cause of death and any treatment prior to deathLung cancer
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Lung cancer
65
No treatment, smoker
Your Mother's Mother
Question Response
Current age or age at death 82
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Your Mother's Sisters 1
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 Mother's Sisters 2
Question Response
Current age or age at death 53
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 62
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 58
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 37
Living / DeadDead
Cause of death and any treatment prior to deathLiver damage, not treated.
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other liver disease
37
Post-mortem diagnosis, no treatment. Abused alcohol.
Your Father's Father
Question Response
Current age or age at death 72
Living / DeadDead
Cause of death and any treatment prior to deathBlood clot due to head trauma from a fall
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
 
No diagnosed health problems at time of death.
Your Father's Mother
Question Response
Current age or age at death 81
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Your Father's Sisters 1
Question Response
Current age or age at death 56
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 49
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 47
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy