Personal Behavior History

Question Response
Current alcohol use:
If yes, oz./week and type of alcohol:		Rarely - Whiskey, 0.5 oz/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?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:		Leg, Wisdom teeth removed - Age10 Broken, Age 19 and 20 (2 surgeries)
Hospitalization other than surgery:
Age & type of illness:		N/A
Have you ever had any broken bones?
If yes, please give age and description:		Yes - 10 Femur broke in ski accident
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:Tums - Once a day; Twice (as needed); Burps were tasting funny
List all current medication or treatments (include vitamins, aspirin, antacids, laxatives, herbal, sports supplements, etc.) Include drug, frequency and duration taken, and reason:Aspirin - Once a day; As needed every couple months; Headache
Do you wear glasses or contact lenses?
Are you near or far-sighted?		Yes - Farsighted, 2/2.5
Birth weight lbs6
Birth weight ozs14
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?0
Have you ever had a tattoo?No
Have you ever had your ear(s) or body pierced?No

Family Medical History
See list of questions asked here

Mother's Father Ethnic OriginsFilipino
Mother's Mother Ethnic OriginsFilipino
Father's Father Ethnic OriginsChinese
Father's Mother Ethnic OriginChinese
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 56
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Your Father
Question Response
Current age or age at death 59
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Sisters
Your Sister 1
Question Response
Current age or age at death 24
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Asthma
1
Exercise, emergency inhaler
Your Mother's Father
Question Response
Current age or age at death 80
Living / DeadDead
Cause of death and any treatment prior to deathStroke
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
 
No other health problems diagnosed at time of death
Your Mother's Mother
Question Response
Current age or age at death 90
Living / DeadDead
Cause of death and any treatment prior to deathHeart failure, passed in sleep
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
 
Had cataracts, age of diagnosis unknown, no treatment
Your Mother's Sisters 1
Question Response
Current age or age at death 74
Living / DeadN/A
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Your Mother's Sisters 2
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
Breast cancer
60
Chemotherapy
Your Mother's Sisters 3
Question Response
Current age or age at death 68
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Your Mother's Sisters 4
Question Response
Current age or age at death 63
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Your Mother's Sisters 5
Question Response
Current age or age at death 60
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Your Mother's Sisters 6
Question Response
Current age or age at death 58
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Your Mother's Brothers 1
Question Response
Current age or age at death 76
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Your Mother's Brothers 2
Question Response
Current age or age at death 65
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Your Mother's Brothers 3
Question Response
Current age or age at death 64
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Your Father's Father
Question Response
Current age or age at death 78
Living / DeadDead
Cause of death and any treatment prior to deathHeart attack
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 84
Living / DeadDead
Cause of death and any treatment prior to deathOrgan failure in nursing home at time of death
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
 
No other diagnosed health problems at time of death
Your Father's Brothers 1
Question Response
Current age or age at death 70
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Your Father's Brothers 2
Question Response
Current age or age at death 65
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Heart attack
60
None