Personal Behavior History
Donor Sexual History
Donor Genetic History
Donor Medical History
Family Medical HistoryPersonal Behavior History
| Question | Response |
| Current alcohol use: If yes, oz./week and type of alcohol: | Rarely - 5 oz. wine/<1x week |
| 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? | No |
| 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: | left elbow Fracture repair, Wisdom tooth extraction, - 10 fell on playground, 21 four teeth removed |
| 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 - 10, left elbow playground injury, 12 right humerus playing football, 12 right ankle fell during theatre play |
| 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: | Vitamin D supplements - Daily; 6 Months; Vitamin deficiency |
| List all current medication or treatments (include vitamins, aspirin, antacids, laxatives, herbal, sports supplements, etc.) Include drug, frequency and duration taken, and reason: | Vitamin D supplements - Daily; 6 months; Vitamin Deficiency |
| Do you wear glasses or contact lenses? Are you near or far-sighted? | Yes - -4.75/-4.75 |
| Birth weight lbs | 6 |
| 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: | No |
| How many sexual partners do you currently have? | 1 |
| Have you ever had a tattoo? | Yes - 2018 Right calf; 2018 Left forearm; 2016 Right shoulder; 2014 Left ankle |
| Have you ever had your ear(s) or body pierced? | No |
Family Medical HistorySee list of questions asked here
| Mother's Father Ethnic Origins | English-Irish |
| Mother's Mother Ethnic Origins | English-French |
| Father's Father Ethnic Origins | Scottish |
| Father's Mother Ethnic Origin | Scottish |
| 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 | 58 |
| 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
40
metoprolol, losartan
Diabetes mellitus not requiring insulin therapy
45
metformin, glipizide and diet change
Thyroid disease
50
hypothyroidism medicated with levothyroxine
Your Father
| 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 Mother's Father
| Question | Response |
| Current age or age at death | 77 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
74 left leg amputation, 77 right leg amputation. Poor circulation secondary to heavy smoking. Wounds on feet became necrotic leading to both amputations.
Your Mother's Mother
| Question | Response |
| Current age or age at death | 66 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Pulmonary Embolism, no treatment |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Any other cancer/problem of digestive system
45
Decreased gastric motility, treated with metoclopramide
Other mental health disorders
60
Psychosis, treated with medication
Your Mother's Sisters 1
| 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 | 45 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Lung cancer |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Lung cancer
40
Cancer was too advanced and aggressive, no treatment
Your Father's Mother
| Question | Response |
| Current age or age at death | 61 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Stomach cancer, no treatment |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Stomach Cancer
60
no treatment