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: | Rarely - Recently quit drinking, previously Mezcal, 4-5x per year |
| 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 |
| Hospitalization other than surgery: Age & type of illness: | Yes - Age 12, appendicitis (no surgery); Age 18, concussion |
| Have you ever had any broken bones? If yes, please give age and description: | Yes - Age 14, left fibula, jumped off porch and landed on uneven ground. |
| 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: | Probiotic - Daily; 10/2020 to Present; Digestive health |
| List all current medication or treatments (include vitamins, aspirin, antacids, laxatives, herbal, sports supplements, etc.) Include drug, frequency and duration taken, and reason: | Probiotic - Daily; 10/2020 to Present; Digestive health |
| Do you wear glasses or contact lenses? Are you near or far-sighted? | Yes - Nearsighted, R: -2.00, -1.00, 180.00 L: -2.00, -1.00, 180.00 |
| Birth weight lbs | 6 |
| Birth weight ozs | 4 |
| Recent weight loss or gain? # of lbs and reason: | Yes - 45 pounds lost, diet and exercise |
| 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 - 2020 Both ears |
Family Medical HistorySee list of questions asked here
| Mother's Father Ethnic Origins | Nicaraguan |
| Mother's Mother Ethnic Origins | Nicaraguan |
| Father's Father Ethnic Origins | Nicaraguan |
| Father's Mother Ethnic Origin | Nicaraguan |
| 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 | 46 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
High cholesterol
43
Diet
Any other cancer/problem of digestive system
43
Gastritis, medication and diet
Your Father
| Question | Response |
| Current age or age at death | 54 |
| 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 | 18 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
Car accident at age 18, suffered fractures to face and skull.
Your Brother 2
| Question | Response |
| Current age or age at death | 12 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Depression
12
Therapy and medication
Your Mother's Father
| Question | Response |
| Current age or age at death | 74 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Stroke and ruptured ulcer |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Ulcer of stomach/duodenum
70
No treatment
Diabetes mellitus requiring insulin therapy
60
Insulin
Drug abuse, misuse, or addiction
42
Alcoholism, no treatment.
Your Mother's Mother
| Question | Response |
| Current age or age at death | 68 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Rheumatoid Arthritis
57
Anti-inflammatory and pain medication
Your Mother's Sisters 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 Mother's Sisters 2
| 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 Mother's Sisters 3
| Question | Response |
| Current age or age at death | 51 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Your Mother's Sisters 4
| Question | Response |
| Current age or age at death | 50 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Your Mother's Sisters 5
| Question | Response |
| Current age or age at death | 49 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Your Mother's Brothers 1
| Question | Response |
| Current age or age at death | 52 |
| 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
45
Diet change
High cholesterol
45
Diet change
Your Mother's Brothers 2
| Question | Response |
| Current age or age at death | 49 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Your Mother's Brothers 3
| Question | Response |
| Current age or age at death | 45 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Your Mother's Brothers 4
| Question | Response |
| Current age or age at death | 38 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Meningitis |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
Hydrocephalus and paraplegia in childhood due to medical malpractice
Your Father's Father
| Question | Response |
| Current age or age at death | 82 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Homicide |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
No diagnosed health problems at time of death.
Your Father's Mother
| Question | Response |
| Current age or age at death | 73 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Stroke |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Stroke
73
Fatal, no treatment
Your Father's Sisters 1
| Question | Response |
| Current age or age at death | 67 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Your Father's Sisters 2
| 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
Healthy