Personal Behavior History

Question Response
Current alcohol use:
If yes, oz./week and type of alcohol:
Never
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:
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:Advil, ibuprofen, allergy meds - As needed, As needed, As needed; No longer than a month; Headache, toothache, seasonal allergies
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 lbs7
Birth weight ozs6
Recent weight loss or gain?
# of lbs and reason:
No
Allergies (medicines, food, pollens)?
If yes, please list substance and reaction caused:
Yes - Pollen, watery eyes and runny nose
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 OriginsBangladeshi
Mother's Mother Ethnic OriginsBangladeshi
Father's Father Ethnic OriginsBangladeshi
Father's Mother Ethnic OriginBangladeshi
Is anyone in your family of Ashkenazai Jewish Heritage?No
If yes, who?N/A
Question Response
Current age or age at death 47
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Migraines
29
Medication
Question Response
Current age or age at death 61
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Asthma
8
Inhaler
Question Response
Current age or age at death 17
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Question Response
Current age or age at death 23
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Asthma
1
Inhaler
Question Response
Current age or age at death 94
Living / DeadDead
Cause of death and any treatment prior to deathOld age (passed away in his sleep)
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
 
No known health problems at time of death
Question Response
Current age or age at death 88
Living / DeadDead
Cause of death and any treatment prior to deathOld age (passed away in nursing home)
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
 
Received nursing care for dementia, age of diagnosis unknown
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 55
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 101
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 94
Living / DeadDead
Cause of death and any treatment prior to deathOld age (passed away in sleep)
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
 
No known health problems at time of death
Question Response
Current age or age at death 67
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