Personal Behavior History
Question | Response |
Current alcohol use: If yes, oz./week and type of alcohol: | Rarely - 8oz - Wine, Vodka, Tequila |
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: | Nyquil - Daily; 1 Week; Cold like symptoms |
List all current medication or treatments (include vitamins, aspirin, antacids, laxatives, herbal, sports supplements, etc.) Include drug, frequency and duration taken, and reason: | Multivitamin - Daily; 3 Years; Overall Health |
Do you wear glasses or contact lenses? Are you near or far-sighted? | No |
Birth weight lbs | 7 |
Birth weight ozs | 2 |
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-Scottish |
Mother's Mother Ethnic Origins | Irish-English-Scottish |
Father's Father Ethnic Origins | Irish-English-Scottish |
Father's Mother Ethnic Origin | Irish-English-Scottish |
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 | 68 |
Living / Dead | Dead |
Cause of death and any treatment prior to death | Heart Failure |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Eating Disorders
40
Anorexia - rehab
Your Father
Question | Response |
Current age or age at death | 74 |
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 | 45 |
Living / Dead | Living |
Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Your Brother 2
Question | Response |
Current age or age at death | 42 |
Living / Dead | Living |
Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Your Brother 3
Question | Response |
Current age or age at death | 40 |
Living / Dead | Living |
Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Your Brother 4
Question | Response |
Current age or age at death | 39 |
Living / Dead | Living |
Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Your Brother 5
Question | Response |
Current age or age at death | 35 |
Living / Dead | Living |
Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Your Brother 6
Question | Response |
Current age or age at death | 0 |
Living / Dead | Dead |
Cause of death and any treatment prior to death | Complications during childbirth, brain bleed and intracranial hemorrhage during labor |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
No other diagnosed health problems at time of death
Sisters
Your Sister 1
Question | Response |
Current age or age at death | 44 |
Living / Dead | Living |
Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Your Sister 2
Question | Response |
Current age or age at death | 37 |
Living / Dead | Living |
Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Your Sister 3
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
Sons
Your Son 1
Question | Response |
Current age or age at death | 2 |
Living / Dead | Living |
Health Problems
Healthy
Your Son 2
Question | Response |
Current age or age at death | 1 |
Living / Dead | Living |
Health Problems
Healthy
Your Mother's Father
Question | Response |
Current age or age at death | 86 |
Living / Dead | Dead |
Cause of death and any treatment prior to death | Colon Cancer |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
Wore hearing aids for hearing loss due to advanced age
Your Mother's Mother
Question | Response |
Current age or age at death | 88 |
Living / Dead | Dead |
Cause of death and any treatment prior to death | Stroke |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
No other diagnosed health problems at time of death
Your Mother's Sisters 1
Question | Response |
Current age or age at death | 73 |
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 | 71 |
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 | 75 |
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 | 82 |
Living / Dead | Dead |
Cause of death and any treatment prior to death | Stroke |
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 | 88 |
Living / Dead | Dead |
Cause of death and any treatment prior to death | Complications of hip fracture due to fall |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Dementia or degenerative disorders
80
Live-in caretaker support
Your Father's Sisters 1
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
Your Father's Sisters 2
Question | Response |
Current age or age at death | 70 |
Living / Dead | Living |
Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy