Personal Behavior History

Question Response
Current alcohol use:
If yes, oz./week and type of alcohol:
Rarely - Beer, 6oz./week
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:
Tonsillectomy - Age 18
Hospitalization other than surgery:
Age & type of illness:
None - None
Have you ever had any broken bones?
If yes, please give age and description:
Yes - Age 17, big toe, dropped a 45 lb. weight on foot.
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:Ibuprofen - 1 a day; 2 weeks; Muscle sprain
List all current medication or treatments (include vitamins, aspirin, antacids, laxatives, herbal, sports supplements, etc.) Include drug, frequency and duration taken, and reason:Calcium supplements - 1 a day; 2 months; Selfcare
Do you wear glasses or contact lenses?
Are you near or far-sighted?
No
Birth weight lbs9
Birth weight ozs0
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?0
Have you ever had a tattoo?No
Have you ever had your ear(s) or body pierced?No

Family Medical History
See list of questions asked here

Mother's Father Ethnic OriginsEnglish
Mother's Mother Ethnic OriginsEnglish
Father's Father Ethnic OriginsMexican
Father's Mother Ethnic OriginMexican
Is anyone in your family of Ashkenazai Jewish Heritage?No
If yes, who?N/A
Question Response
Current age or age at death 58
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Question Response
Current age or age at death 56
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Question Response
Current age or age at death 32
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Question Response
Current age or age at death 28
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Question Response
Current age or age at death 26
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Question Response
Current age or age at death 77
Living / DeadDead
Cause of death and any treatment prior to deathDisease caused by work-related asbestos exposure
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 74
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Question Response
Current age or age at death 54
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Question Response
Current age or age at death 89
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 74
Living / DeadDead
Cause of death and any treatment prior to deathDiabetes
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Diabetes mellitus not requiring insulin therapy
60
Metformin
Question Response
Current age or age at death 62
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Question Response
Current age or age at death 60
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Question Response
Current age or age at death 47
Living / DeadDead
Cause of death and any treatment prior to deathAccidental Death
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
 
No diagnosed health problems at time of death
Question Response
Current age or age at death 39
Living / DeadDead
Cause of death and any treatment prior to deathAccidental Death
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
 
No diagnosed health problems at time of death
Question Response
Current age or age at death 69
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Question Response
Current age or age at death 68
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Question Response
Current age or age at death 66
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Question Response
Current age or age at death 58
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Question Response
Current age or age at death 44
Living / DeadDead
Cause of death and any treatment prior to deathAccidental Death
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
 
No diagnosed health problems at time of death
Question Response
Current age or age at death 42
Living / DeadDead
Cause of death and any treatment prior to deathAccidental Death
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
 
No diagnosed health problems at time of death