Personal Behavior History

Question Response
Current alcohol use:
If yes, oz./week and type of alcohol:		Rarely - 6 oz. Cocktails
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:		Lung surgery; Hernia surgery; Wisdom teeth removal - Age 27, collapsed lung; Age 35, hernia; Age 30
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:Oxycodone, Tylenol, Ibuprofen - Every 6 hours; 3-4 days; Recovering from hernia surgery
List all current medication or treatments (include vitamins, aspirin, antacids, laxatives, herbal, sports supplements, etc.) Include drug, frequency and duration taken, and reason:None - N/A; N/A; N/A
Do you wear glasses or contact lenses?
Are you near or far-sighted?		Yes - Near-sighted, -1.25/-1.75
Birth weight lbs5
Birth weight ozs9
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 History
See list of questions asked here

Mother's Father Ethnic OriginsGerman-Norwegian
Mother's Mother Ethnic OriginsGerman-Swedish
Father's Father Ethnic OriginsGerman
Father's Mother Ethnic OriginGerman
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 65
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other heart disease
64
Stents in heart
Breast cancer
52
Surgery and chemotherapy, double mastectomy, no BRCA testing
Your Father
Question Response
Current age or age at death 62
Living / DeadDead
Cause of death and any treatment prior to deathPresumably Drowned, went kayaking and never returned
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Diabetes mellitus requiring insulin therapy
57
Diet management
Inguinal hernia
39
Surgery
Brothers
Your Brother 1
Question Response
Current age or age at death 39
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Your Brother 2
Question Response
Current age or age at death 35
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Sons
Your Son 1
Question Response
Current age or age at death 7
Living / DeadLiving
Health Problems
Healthy
Your Son 2
Question Response
Current age or age at death 3
Living / DeadLiving
Health Problems
Healthy
Daughters
Your Daughter 1
Question Response
Current age or age at death 5
Living / DeadLiving
Health Problems
Healthy
Your Mother's Father
Question Response
Current age or age at death 82
Living / DeadDead
Cause of death and any treatment prior to deathAlzheimer’s, medication
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Alzheimer's
79
Medication
Any other sight/sound/smell disorder
55
Eye cancer, surgically removed eye
Your Mother's Mother
Question Response
Current age or age at death 91
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Osteoporosis
80
Medication
Your Mother's Sisters 1
Question Response
Current age or age at death 69
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Your Mother's Sisters 2
Question Response
Current age or age at death 67
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Your Mother's Sisters 3
Question Response
Current age or age at death 62
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Your Mother's Sisters 4
Question Response
Current age or age at death 60
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Your Mother's Brothers 1
Question Response
Current age or age at death 64
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Your Mother's Brothers 2
Question Response
Current age or age at death 58
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Your Father's Father
Question Response
Current age or age at death 61
Living / DeadDead
Cause of death and any treatment prior to deathHeart Attack
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 79
Living / DeadDead
Cause of death and any treatment prior to deathBrain Cancer
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Miscarriages or stillborn
23
2 Miscarriages, Age 23 and 25
Brain tumor
75
Chemo radiation, no surgery