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 - Jack and Coke occasionally |
| 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: | N/A - N/A |
| 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: | 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: | N/A - 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: | Tylenol - Once last month; Two pills every 8 hours for a 24 hour cycle; Headache from work |
| Do you wear glasses or contact lenses? Are you near or far-sighted? | Yes - far sighted, 20/100 |
| Birth weight lbs | 8 |
| Birth weight ozs | 1 |
| 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? | No |
Family Medical HistorySee list of questions asked here
| Mother's Father Ethnic Origins | Irish-English |
| Mother's Mother Ethnic Origins | Irish-English |
| Father's Father Ethnic Origins | Canadian |
| Father's Mother Ethnic Origin | Canadian |
| 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 | 57 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Thyroid disease
45
Removed thyroid due to benign mass/hypothyroidism, also treated with medication
Other
Diagnosed with bulging disc in back at age 57, treatment not yet determined. Diagnosed with factor V clotting disorder in her 20s, no treatment.
Your Father
| Question | Response |
| Current age or age at death | 72 |
| 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 | 29 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Thyroid disease
29
Hyperthyroidism, treated with medication
Other
Diagnosed with factor V clotting disorder at age 29, no treatment
Your Mother's Father
| Question | Response |
| Current age or age at death | 78 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Pneumonia, hospitalization |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
High blood pressure
50
Medication
Your Mother's Mother
| Question | Response |
| Current age or age at death | 75 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Parkinson’s/Alzheimer’s |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Alzheimer's
74
Nursing care
Parkinson's disease
74
Nursing care
Your Mother's Sisters 1
| Question | Response |
| Current age or age at death | 53 |
| 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 | 78 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Lung Disease, no treatment |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
No other diagnosed health problems at time of death
Your Father's Mother
| Question | Response |
| Current age or age at death | 35 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Lung cancer (smoker), no treatment |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Early death (less than age 50)
35
Lung cancer, no treatment
Your Father's Sisters 1
| Question | Response |
| Current age or age at death | 71 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy