Personal Behavior History

Question Response
Current alcohol use:
If yes, oz./week and type of alcohol:
Never
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:
Tonsil removal - Age 4 due to chronic ear infections
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:None - None; None; None
List all current medication or treatments (include vitamins, aspirin, antacids, laxatives, herbal, sports supplements, etc.) Include drug, frequency and duration taken, and reason:Pre workouts, protein powder, BCAA supplements, Advil - Preworkouts 3 times a week and protein daily. Advil as needed maybe once a month max; 3 times weekly; I work out so I use the supplements to increase my bodies efficiency to build muscle. And I have headaches rarely
Do you wear glasses or contact lenses?
Are you near or far-sighted?
No
Birth weight lbs8
Birth weight ozs6
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
Tattoo#1 Year2014
Tattoo#1 LocationLeft arm
Tattoo#2 Year2014
Tattoo#2 LocationRight arm
Tattoo#3 Year2014
Tattoo#3 LocationRight arm
Question Response
Have you ever had your ear(s) or body pierced?No

Family Medical History
See list of questions asked here

Mother's Father Ethnic OriginsAfrican American
Mother's Mother Ethnic OriginsAfrican American
Father's Father Ethnic OriginsAfrican American
Father's Mother Ethnic OriginAfrican American-Dominican-Caucasian
Is anyone in your family of Ashkenazai Jewish Heritage?No
If yes, who?N/A
Question Response
Current age or age at death 46
Living / DeadDead
Cause of death and any treatment prior to deathPoorly managed diabetes due to unhealthy lifestyle. Overweight and smoked heavily.
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Diabetes mellitus requiring insulin therapy
24
Insulin
Question Response
Current age or age at death 50
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Question Response
Current age or age at death 14
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Question Response
Current age or age at death 12
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Question Response
Current age or age at death 71
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Question Response
Current age or age at death 80
Living / DeadDead
Cause of death and any treatment prior to deathHeart failure
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
 
No other diagnosed health problems at time of death
Question Response
Current age or age at death 35
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Question Response
Current age or age at death 70
Living / DeadDead
Cause of death and any treatment prior to deathRespiratory failure, passed in sleep
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Dementia or degenerative disorders
69
None
Question Response
Current age or age at death 76
Living / DeadDead
Cause of death and any treatment prior to deathSuicide
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Suicide or suicide attempts
76
No diagnoses of mental health diseases, lived a tough life
Question Response
Current age or age at death 62
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy