Personal Behavior History

Question Response
Current alcohol use:
If yes, oz./week and type of alcohol:		Occasionally - 1 oz, liquor
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 - 29
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 - Hairline fracture on nose at age 21. No displaced bones. Work related injury (tire iron slipped and hit my nose).
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 loratadine Acetaminophen, Olly Men’s multivitamin, - Very Rare, for occasional headache; Only as needed for headache; Headache or congestion
List all current medication or treatments (include vitamins, aspirin, antacids, laxatives, herbal, sports supplements, etc.) Include drug, frequency and duration taken, and reason:Ibuprofen loratadine Acetaminophen, Olly Men’s multivitamin, Alka seltzer antacids - As Needed; Only as needed; Headache stomachache or congestion
Do you wear glasses or contact lenses?
Are you near or far-sighted?		No
Birth weight lbs9
Birth weight ozs1
Recent weight loss or gain?
# of lbs and reason:		No
Allergies (medicines, food, pollens)?
If yes, please list substance and reaction caused:		Yes - Minor Seasonal allergies cause congestion, sneezing, watery eyes
How many sexual partners do you currently have?1
Have you ever had a tattoo?Yes - 2010 Chest; 2011, Upper back; 2014, left and right side of torso; 2013 Left shoulder and left inner bicep; 2015, left bicep; 2016 left forearm; 2013 Right shoulder and bicep; 2014, right inner bicep
Have you ever had your ear(s) or body pierced?Yes - 2006 Ears

Family Medical History
See list of questions asked here

Mother's Father Ethnic OriginsAfrican American
Mother's Mother Ethnic OriginsAfrican American
Father's Father Ethnic OriginsAfrican American
Father's Mother Ethnic OriginNative American
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
48
Diet changes
Your Father
Question Response
Current age or age at death 50
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
Sisters
Your Sister 1
Question Response
Current age or age at death 31
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
17
Diet changes
Your Sister 2
Question Response
Current age or age at death 16
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Sons
Your Son 1
Question Response
Current age or age at death 4
Living / DeadLiving
Health Problems
Healthy
Daughters
Your Daughter 1
Question Response
Current age or age at death 5
Living / DeadLiving
Health Problems
Healthy
Your Daughter 2
Question Response
Current age or age at death 1
Living / DeadLiving
Health Problems
Healthy
Your Mother's Father
Question Response
Current age or age at death 38
Living / DeadDead
Cause of death and any treatment prior to deathMurdered
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Early death (less than age 50)
38
Fatally stabbed, no treatment
Your Mother's Mother
Question Response
Current age or age at death 71
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
Disease
Age Diagnosed
Treatment For Condition
Other
 
Estranged, health status unknown
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
Disease
Age Diagnosed
Treatment For Condition
Other
 
AIDS, age of diagnosis and treatment unknown
Your Mother's Brothers 3
Question Response
Current age or age at death 54
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
 
Estranged, health status unknown
Your Father's Father
Question Response
Current age or age at death 78
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 35
Living / DeadDead
Cause of death and any treatment prior to deathMurdered
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Early death (less than age 50)
35
Murdered, no treatment