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: | Rarely - An occasional beer |
| 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 extraction; Varicocele ligation - Age 20 routine procedure; Age 20 Varicocele Ligation due to scrotal pain |
| 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: | 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: | 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 - N/A; N/A; 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: | N/A - N/A; N/A; N/A |
| Do you wear glasses or contact lenses? Are you near or far-sighted? | Yes - -1.25/-1.5, near-sighted, age 14 |
| Birth weight lbs | 7 |
| Birth weight ozs | 1 |
| Recent weight loss or gain? # of lbs and reason: | No |
| Allergies (medicines, food, pollens)? If yes, please list substance and reaction caused: | Yes - Penicillin, causes hives |
| 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 HistorySee list of questions asked here
| Mother's Father Ethnic Origins | Ukrainian |
| Mother's Mother Ethnic Origins | Norwegian |
| Father's Father Ethnic Origins | Swedish |
| Father's Mother Ethnic Origin | Swedish |
| 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 | 67 |
| 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
65
Medication
High cholesterol
65
Medication
Your Father
| Question | Response |
| Current age or age at death | 59 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Heart Attack |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Heart attack
59
Immediately Fatal
High blood pressure
55
Not treated
Brothers
Your Brother 1
| Question | Response |
| Current age or age at death | 34 |
| 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 | 36 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Your Mother's Father
| Question | Response |
| Current age or age at death | 79 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Stroke |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Stroke
79
Fatal, was smoker
High blood pressure
60
Medication
Progressive kidney disease
60
Medication
Drug abuse, misuse, or addiction
No treatment, suffered with alcoholism entire adult life
Your Mother's Mother
| Question | Response |
| Current age or age at death | 89 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Old Age. Combination of health problems below |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
High blood pressure
75
Medication
Other lung disease
75
COPD, lifelong smoker
Dementia or degenerative disorders
85
Medication
Osteoporosis
65
Medication
Your Mother's Sisters 1
| 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 Mother's Sisters 2
| 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
Healthy
Your Mother's Sisters 3
| Question | Response |
| Current age or age at death | 60 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Your Mother's Sisters 4
| 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
Healthy
Your Mother's Brothers 1
| Question | Response |
| Current age or age at death | 64 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Esophageal Cancer |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Any other cancer/problem of digestive system
62
Esophageal cancer, treated with chemotherapy, surgery; lifelong smoker
Your Mother's Brothers 2
| Question | Response |
| Current age or age at death | 62 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Esophageal Cancer |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Any other cancer/problem of digestive system
60
Esophageal cancer, treated with chemotherapy, surgery; lifelong smoker
Your Mother's Brothers 3
| Question | Response |
| Current age or age at death | 62 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Your Father's Father
| Question | Response |
| Current age or age at death | 83 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Car Accident |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
High blood pressure
65
Medication
Other
Enlarged prostate diagnosed at age 65, treated with medication. Negative for cancer.
Your Father's Mother
| Question | Response |
| Current age or age at death | 81 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Kidney Disease, Transient Ischaemic Strokes |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
High blood pressure
70
Medication, diet
Progressive kidney disease
75
Dialysis, medication
Dementia or degenerative disorders
75
Medication
Your Father's Brothers 1
| Question | Response |
| Current age or age at death | 78 |
| 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 | 73 |
| 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
65
Medication