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 - 12 oz beer twice/month if that |
| 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? | Yes |
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: | Appendectomy, Wisdom teeth extraction - Age 16 due to necessity, Age 17 due to routine procedure |
| Hospitalization other than surgery: Age & type of illness: | NA - NA |
| 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: | Tylenol, Melatonin, Marijuana - Very Seldom; as needed; pain, sleep aid |
| List all current medication or treatments (include vitamins, aspirin, antacids, laxatives, herbal, sports supplements, etc.) Include drug, frequency and duration taken, and reason: | N/A - N/A; N/A; N/A |
| Do you wear glasses or contact lenses? Are you near or far-sighted? | No |
| Birth weight lbs | 9 |
| Birth weight ozs | 0 |
| Recent weight loss or gain? # of lbs and reason: | No |
| Allergies (medicines, food, pollens)? If yes, please list substance and reaction caused: | Yes - Spring allergies - Stuffy nose, takes Zyrtec as needed |
| How many sexual partners do you currently have? | 0 |
| Have you ever had a tattoo? | Yes - 2009 Right Arm; 2007 Right Foot |
| Have you ever had your ear(s) or body pierced? | Yes - 2009 Left Ear |
Family Medical HistorySee list of questions asked here
| Mother's Father Ethnic Origins | Irish-German |
| Mother's Mother Ethnic Origins | Irish-German-French |
| Father's Father Ethnic Origins | Irish-French |
| Father's Mother Ethnic Origin | Irish |
| 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
Healthy
Your Father
| 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
Brothers
Your Brother 1
| Question | Response |
| Current age or age at death | 33 |
| 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 | 28 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Sons
Your Son 1
| Question | Response |
| Current age or age at death | 2 |
| Living / Dead | Living |
Health Problems
Healthy
Your Mother's Father
| Question | Response |
| Current age or age at death | 55 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Heart Attack |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
No other diagnosed health problems at time of death
Your Mother's Mother
| Question | Response |
| Current age or age at death | 82 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Heart Failure |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Drug abuse, misuse, or addiction
30
Dealt with alcohol abuse during different times throughout life. Age is approximate
Your Mother's Sisters 1
| Question | Response |
| Current age or age at death | 60 |
| 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 | 63 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Your Mother's Brothers 2
| Question | Response |
| Current age or age at death | 55 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Heart Attack |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
Diagnosed with HIV/AIDS at age 25, treated with medication
Your Mother's Brothers 3
| Question | Response |
| Current age or age at death | 55 |
| 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 | 53 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Bone Cancer |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
Osteosarcoma diagnosed at age 52 treated with chemotherapy
Your Father's Mother
| Question | Response |
| Current age or age at death | 39 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Leukemia |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
No other diagnosed health problems at time of death
Your Father's Sisters 1
| Question | Response |
| Current age or age at death | 65 |
| 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 | 62 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Your Father's Sisters 3
| Question | Response |
| Current age or age at death | 60 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Your Father's Sisters 4
| 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
Healthy
Your Father's Brothers 1
| Question | Response |
| Current age or age at death | 64 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Your Father's Brothers 2
| Question | Response |
| Current age or age at death | 61 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy