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:
Ganglion cyst excision (wrist) - Age 17, no pain and wasn't apparent, just wanted to take care of it early
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:Vitamin D, fish oil - Every other day, Daily; Years, Years; Supplement
List all current medication or treatments (include vitamins, aspirin, antacids, laxatives, herbal, sports supplements, etc.) Include drug, frequency and duration taken, and reason:Vitamin D, Fish oil - Every other day, Daily; Years, Years; Supplement
Do you wear glasses or contact lenses?
Are you near or far-sighted?
No
Birth weight lbs6
Birth weight ozs2
Recent weight loss or gain?
# of lbs and reason:
No
Allergies (medicines, food, pollens)?
If yes, please list substance and reaction caused:
Yes - Amoxicillin/Levofloxacin: Hives
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 OriginsFrench
Mother's Mother Ethnic OriginsSwedish-Italian
Father's Father Ethnic OriginsKorean
Father's Mother Ethnic OriginKorean
Is anyone in your family of Ashkenazai Jewish Heritage?No
If yes, who?N/A
Question Response
Current age or age at death 51
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Question Response
Current age or age at death 52
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Disease
Age Diagnosed
Treatment For Condition
High blood pressure
37
Diet change, exercise
Question Response
Current age or age at death 15
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Question Response
Current age or age at death 13
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 / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Disease
Age Diagnosed
Treatment For Condition
High cholesterol
55
Diet and exercise
Question Response
Current age or age at death 71
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 / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Systemic lupus
22
Medication
Question Response
Current age or age at death 46
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Disease
Age Diagnosed
Treatment For Condition
High blood pressure
31
Diet, exercise
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 68
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 54
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy