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
Personal Behavior History
| Question | Response |
| Current alcohol use: If yes, oz./week and type of alcohol: | Occasionally - 3 oz once a week of red wine |
| 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 - Age 15 and because they began to grow in so my parents proactively removed them |
| 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 - 2 fingers on left hand after falling while playing basketball. Age 16. Also broken nose at age 16 from water polo. Quick surgery. No hospitalization. |
| 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: | Ibuprofen after a long day of riding a dirt bike in the sand (July 2020), Marijuana to try it (April 2020) |
| List all current medication or treatments (include vitamins, aspirin, antacids, laxatives, herbal, sports supplements, etc.) Include drug, frequency and duration taken, and reason: | None |
| Do you wear glasses or contact lenses? Are you near or far-sighted? | No |
| Birth weight lbs | 7 |
| Birth weight ozs | 14 |
| Recent weight loss or gain? # of lbs and reason: | No |
| Allergies (medicines, food, pollens)? If yes, please list substance and reaction caused: | Yes - Doxycycline, hives and breathing difficulty |
| 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? | No |
Family Medical HistorySee list of questions asked here
| Mother's Father Ethnic Origins | Irish |
| Mother's Mother Ethnic Origins | German-Austrian |
| Father's Father Ethnic Origins | Welsh |
| Father's Mother Ethnic Origin | Welsh |
| 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 | 52 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Hay fever/Seasonal Allergies/Allergic Rhinitis
25
Oral Antihistamines
Your Father
| Question | Response |
| Current age or age at death | 59 |
| 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
55
Exercise and healthy diet
Acne
15
Topical
Obesity
55
Exercise and healthy diet
Sisters
Your Sister 1
| Question | Response |
| Current age or age at death | 20 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Hay fever/Seasonal Allergies/Allergic Rhinitis
19
Oral Antihistamines
Obesity
17
Exercise and healthy diet
Daughters
Your Daughter 1
| Question | Response |
| Current age or age at death | 6 |
| Living / Dead | Living |
Health Problems
Healthy
Your Mother's Father
| 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
High blood pressure
70
Exercise, healthy diet, and medication
Other
Sleep apnea diagnosed at age 50. Corrected by surgery.
Your Mother's Mother
| 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
Disease
Age Diagnosed
Treatment For Condition
Hay fever/Seasonal Allergies/Allergic Rhinitis
20
Oral Antihistamines
Your Father's Father
| Question | Response |
| Current age or age at death | 89 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Heart attack |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Heart attack
89
Fatal, no treatment
Your Father's Mother
| Question | Response |
| Current age or age at death | 50 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Car accident |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Acne
16
Topical
Your Father's Sisters 1
| Question | Response |
| Current age or age at death | 57 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Migraines
16
Pain relieving medication
Your Father's Brothers 1
| Question | Response |
| Current age or age at death | 51 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy