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 - 36 oz., various |
| 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: | ACL Reconstruction, ACL Reconstruction, Labrum Tear, Labrum Tear - 2007 Injury, 2008 Injury, 2010 Injury, 2011 Injury |
| Hospitalization other than surgery: Age & type of illness: | Yes - 5 - Giardia, 17 - Migraine |
| Have you ever had any broken bones? If yes, please give age and description: | Yes - Age 14, patella, football injury |
| Have you ever had any serious illnesses? If yes, please give age and description: | Yes - 5 - Giardia |
| 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, allergy meds, and z pack - Occasionally; As directed; General, allergies, infection |
| List all current medication or treatments (include vitamins, aspirin, antacids, laxatives, herbal, sports supplements, etc.) Include drug, frequency and duration taken, and reason: | Daily vitamin - Daily; Everyday; General Health |
| Do you wear glasses or contact lenses? Are you near or far-sighted? | No |
| Birth weight lbs | 7 |
| Birth weight ozs | 2 |
| Recent weight loss or gain? # of lbs and reason: | Yes - 30 lbs and needed to lose weight |
| Allergies (medicines, food, pollens)? If yes, please list substance and reaction caused: | Yes - Compazine, caused seizures |
| How many sexual partners do you currently have? | 1 |
| Have you ever had a tattoo? | Yes - 2008 Shoulder; 2021 Calf |
| 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-Native American |
| Father's Father Ethnic Origins | English-Scottish-Irish |
| Father's Mother Ethnic Origin | French-English-Irish |
| 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 | 59 |
| 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 | 57 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
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 | 38 |
| 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 | COPD, treated with oxygen |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
No other diagnosed health problems
Your Mother's Mother
| Question | Response |
| Current age or age at death | 55 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Car accident |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
No other diagnosed health problems at time of death
Your Mother's Brothers 1
| Question | Response |
| Current age or age at death | 56 |
| 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 | 71 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Complications from ankle surgery |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
No other health problems diagnosed at time of death
Your Father's Mother
| Question | Response |
| Current age or age at death | 72 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Respiratory failure |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other lung disease
60
Oxygen
Osteoporosis
60
Medication
Your Father's Brothers 1
| 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