Personal Behavior History

Question Response
Current alcohol use:
If yes, oz./week and type of alcohol:
Frequently - 36 oz., 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

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:
3 knee surgeries - 16, ACL and meniscal tears; 19, meniscal repair; 21, meniscectomy
Hospitalization other than surgery:
Age & type of illness:
1 week after a bike accident - 14, bike accident, concussion
Have you ever had any broken bones?
If yes, please give age and description:
Yes - Age 17, wrist, basketball injury
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 - As needed; As needed; Headaches and muscle aches
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?
No
Birth weight lbs8
Birth weight ozs10
Recent weight loss or gain?
# of lbs and reason:
No
Allergies (medicines, food, pollens)?
If yes, please list substance and reaction caused:
No
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?Yes
Piercing #1 Year1994
Piercing #1 LocationLeft ear

Family Medical History
See list of questions asked here

Mother's Father Ethnic OriginsIrish
Mother's Mother Ethnic OriginsEnglish
Father's Father Ethnic OriginsEnglish
Father's Mother Ethnic OriginGerman
Is anyone in your family of Ashkenazai Jewish Heritage?No
If yes, who?N/A
Question Response
Current age or age at death 61
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Disease
Age Diagnosed
Treatment For Condition
High blood pressure
57
Medication
Emphysema
54
Smoking cessation and inhaler
Question Response
Current age or age at death 61
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Disease
Age Diagnosed
Treatment For Condition
High blood pressure
55
Medication
Question Response
Current age or age at death 36
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Migraines
14
Abortive therapy (Imitrex and/or ibuprofen)
Question Response
Current age or age at death 2
Living / DeadLiving
Health Problems
Healthy
Question Response
Current age or age at death 70
Living / DeadDead
Cause of death and any treatment prior to deathComplications from a stroke (heavy smoker)
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
 
No other health problems diagnosed at time of death
Question Response
Current age or age at death 40
Living / DeadDead
Cause of death and any treatment prior to deathCar accident
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Early death (less than age 50)
40
Fatal car accident, no treatment
Question Response
Current age or age at death 70
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
 
Rosacea, no treatment
Question Response
Current age or age at death 70
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Question Response
Current age or age at death 55
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Question Response
Current age or age at death 51
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Question Response
Current age or age at death 68
Living / DeadDead
Cause of death and any treatment prior to deathComplications from war injuries (TBI, double leg amputation)
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Diabetes mellitus not requiring insulin therapy
60
Diet changes
Question Response
Current age or age at death 87
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Parkinson's disease
78
Medication
Osteoarthritis
75
Double knee replacement
Other
 
Second knee replacement do to allergic reaction to nickel implants
Question Response
Current age or age at death 66
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Question Response
Current age or age at death 68
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Question Response
Current age or age at death 60
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Disease
Age Diagnosed
Treatment For Condition
High blood pressure
52
Medication and lifestyle changes
Question Response
Current age or age at death 59
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy