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: | Regularly - 48 oz./week, beer |
| 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: | Inguinal hernia repair - Less than 1, to repair hernia in abdomen |
| 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: | Asprin - As needed; As needed; Deal with headache or sore muscles |
| List all current medication or treatments (include vitamins, aspirin, antacids, laxatives, herbal, sports supplements, etc.) Include drug, frequency and duration taken, and reason: | Mutivitamin - Daily; 10 years; Maintain balanced health |
| Do you wear glasses or contact lenses? Are you near or far-sighted? | Yes - Near-sighted, -2.5 both |
| Birth weight lbs | 6 |
| 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 | English |
| Mother's Mother Ethnic Origins | English-German |
| Father's Father Ethnic Origins | Irish |
| 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 | 69 |
| 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 | 64 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Esophageal Cancer |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Kidney Stones
61
Ultrasound therapy, diet changes
Sisters
Your Sister 1
| Question | Response |
| Current age or age at death | 36 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Your Mother's Father
| Question | Response |
| Current age or age at death | 87 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Stroke, no treatment |
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 | 92 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Infection developed after injury from fall |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Any other sight/sound/smell disorder
80
Cataracts, treated with surgery
Your Mother's Brothers 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 Mother's Brothers 2
| Question | Response |
| Current age or age at death | 65 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | COPD (smoker) |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
Used an oxygen tank to treat emphysema (age of diagnosis unknown)
Your Mother's Brothers 3
| Question | Response |
| Current age or age at death | 55 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Emphysema |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
No other diagnosed health problems at time of death
Your Father's Father
| Question | Response |
| Current age or age at death | 70 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Liver failure |
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 | 70 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Pneumonia |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Breast cancer
55
Chemotherapy and radiation
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 | 64 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Specific cause unknown, poor lifestyle, avoided doctors |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
Suffered a back injury (age unknown) that prevented her from working
Your Father's Sisters 3
| 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 Father'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