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: | Frequently - 12 oz/week of wine or 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: | Lymph Node Removal; deviated septum surgery - Age 10, They had fused together after I had the flu, doctors were worried it would be cancerous (it was not). Age 28, deviated septum surgery voluntary to improve breathing and help with allergies/congestion. |
| Hospitalization other than surgery: Age & type of illness: | 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: | None - 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: | Ibuprofen, Allergy - As needed; As needed; Occasional headache/allergies. |
| Do you wear glasses or contact lenses? Are you near or far-sighted? | No |
| Birth weight lbs | 9 |
| Birth weight ozs | 8 |
| Recent weight loss or gain? # of lbs and reason: | No |
| Allergies (medicines, food, pollens)? If yes, please list substance and reaction caused: | Yes - Penicillin - hives. Bivalves (Oysters, Clams): Nausea and vomiting. Cedar pollen get congestion/headaches |
| 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 | Italian |
| Mother's Mother Ethnic Origins | Irish |
| Father's Father Ethnic Origins | Irish-Italian |
| Father's Mother Ethnic Origin | Irish-Polish |
| 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
Healthy
Your 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
Other
Pancreatitis due to a gallstone at age 75, medication and surgery
Brothers
Your Brother 1
| Question | Response |
| Current age or age at death | 43 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Your Brother 2
| Question | Response |
| Current age or age at death | 41 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Your Brother 3
| Question | Response |
| Current age or age at death | 39 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Your Brother 4
| Question | Response |
| Current age or age at death | 37 |
| 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 | 96 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Stroke |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
High blood pressure
96
Medication
Your Mother's Mother
| Question | Response |
| Current age or age at death | 70 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Heart Attack |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Heart attack
70
No treatment
Your Mother's Brothers 1
| Question | Response |
| Current age or age at death | 63 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Your Mother's Brothers 2
| Question | Response |
| Current age or age at death | 61 |
| 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 | 65 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Heart attack |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Heart attack
65
No treatment
Your Father's Mother
| Question | Response |
| Current age or age at death | 91 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Health deteriorated after fall, hospitalization after fall |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
No other health problems diagnosed at time of death.
Your Father's Brothers 1
| Question | Response |
| Current age or age at death | 88 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Heart attack, hospitalization |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
No other health problems diagnosed at time of death.
Your Father's Brothers 2
| Question | Response |
| Current age or age at death | 84 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Heart attack
84
Hospitalization
Your Father's Brothers 3
| Question | Response |
| Current age or age at death | 81 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Your Father's Brothers 4
| 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
Healthy