Fairfax Cryobank
Donor 2184 Medical Profile


Questions
Personal Behavior History
Donor Genetic History
Donor Medical History
Family Medical History

Personal Behavior History
QuestionResponse
Alcohol use:
If yes, oz./week and type of alchohol:		 Occasionally - Beer on weekends
Any relatives with alcoholism?
If yes, relation and age affected:		 No
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
How many packs per day? 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
Any dietary restriction?
If yes, explain:		 No

Sexual History

Have you ever had sex with:
QuestionResponse
Another man anal or oral, even once, since 1977? No
A person having non-medical intravenous, intramuscular, or subcutaneous injection of drugs not prescribed by a physician for medical purposes since 1977? No
A person having engaged in sex in exchange for money or drugs at any time since 1977? No
A person who has had sex with another person described in any of the above in the preceding 12 months? No

Have you:
QuestionResponse
Have you been exposed to known or suspected HIV-infected blood through percutaneous inoculation or through contact with an open wound, non-intact skin, or mucous membrane within the preceding 12 months?  No

Donor Genetic History
QuestionResponse
Were you born with any birth defects?
If yes, explain:		 No
Are there any known genetic conditions or birth defects in your family? No
Have you been tested for Cystic Fibrosis?
If yes, the result:		 Yes - During the donor screening process - non-carrier
Have you been tested for Alpha-1 Antitrypsin Disorder?
If yes, the result:		 Yes - During the donor screening process - non-carrier

Ancestry
QuestionResponse
Are you of Jewish ancestry?
If yes, please note: Ashkenazi, Sephardi, or Other		 No

If you are of Jewish ancestry, have you been tested as a carrier of any of the following diseases?
QuestionResponse
Tay Sachs:
If yes, result(s):		 N/A - N/A
Gaucher:
If yes, result(s):		 N/A - N/A
Canavan:
If yes, result(s):		 N/A - N/A

Ancestry
QuestionResponse
Are you of African ancestry? No
If yes, have you been tested as a carrier of sickle cell anemia? N/A - N/A
If yes, result: N/A
Are you of Mediterranean, Greek or Italian ancestry? Yes
If yes, have you been tested as a carrier of thalassemia? Yes - During the donor screening process - non-carrier
If yes, result: N/A

Have you, any member of your family, or any relative had or currently have any of the following conditions? Explain any conditions, indicating which side of the family (maternal/paternal), the age of the family member at the onset of the condition/
problem, and any other pertinent information.
Heart attack 
No
Congenital heart disease 
No
Hemophilia/bleeding problem 
No
Severe bleeding tendency 
No
Cystic Fibrosis 
No
Alpha-1 Antitrypsin Disorder 
No
Pyloric stenosis 
No
Inflammatory bowel disease 
No
Diabetes mellitus requiring insulin therapy. 
No
Diabetes mellitus not requiring insulin therapy. 
No
PKU or inherited metabolism disorder 
No
Progressive kidney disease 
No
Polycystic kidney disease 
No
Miscarriages or stillborn 
No
Herpes simplex virus, genital 
No
Migraines 
No
Mental retardation 
No
Senility or mental deterioration before age 60 
No
Epilepsy/seizures 
No
Neural tube defects - open spine or hypocephalus/water on the brain 
No
Huntington's disease 
No
Tuberous sclerosis 
No
Neurofibromatosis 
No
Parkinson's disease 
No
Down's syndrome/Mongolism 
No
Schizophrenia 
No
Manic depressive psychosis 
No
Muscular dystrophy 
No
Loss of muscle coordination 
No
Rheumatoid arthritis 
Yes - Father - 40, Maternal Grandmother - 50
Reiter's disease 
No
Club foot 
No
Deafness before age of 60 
No
Cataracts before age of 60 
No
Blindness in both eyes before age of 60 
No
Glaucoma 
No
Psoriasis 
No
Albinism 
No
More than 5 purple or coffee-colored spots on the skin (size of a quarter or larger) 
No
Drug abuse, misuse, or addiction 
No
Cleft palate or cleft lip 
No
Serious birth defects 
No
Inguinal hernia 
No
Premature degeneration of any organ system 
No
The same cancer in more than one family member 
No

Donor Medical History
QuestionResponse
List any operations:
Year & reason:		 Yes - Wisdom teeth removed 8 years ago
Hospitalization other than surgery:
Year & type of illness:		 No
Have you ever had any broken bones?
If yes, please describe:		 Yes - Nose broken in an accident
Have you ever had any serious illnesses?
If yes, please describe:		 No
How many days in the past 12 months could you not work because of all illness (colds, flu, accidents, surgery, etc)?
Please describe:		  Two
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: Zyrtec - daily for 6 weeks for 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: None
Do you wear glasses or contact lenses?
Are you near or far-sighted?		 No
Usual weight?  180
Recent loss or gain?
# of lbs and reason:		 No
Allergies (medicines, food, pollens)?
If yes, please list substance and reaction caused:		 Yes - Pollens in spring and summer
Have you ever had occupational exposure to radiation or chemicals?
If yes, please describe:		 Yes - Mix chemicals for photography classes once per week during school year
Have you had a fever with headache in the last seven days?
If yes, when and why?		 N/A
Have you ever been refused as a blood donor?
If yes, when and why?		 No
Have you been tested for HIV (AIDS)?
If yes, when:		 Yes - One year ago, negative, to be safe
Sexual orientation: Heterosexual
Number of current sexual partners: 1
Has any sexual partner ever been positive for HIV (AIDS)?
If yes, describe:		 No
Has any sexual partner had an episode of trichmoniasis?
If yes, describe:		 No
Have you ever been convicted of a felony?
If yes, please explain:		 No
Have you ever had a tattoo?
If yes, what year did you get the tattoo?		 No
Have you ever had your ear(s) or body pierced?
If yes, where and what year?		 No
Have you had a blood transfusion in the last 12 months?
If yes, what was the date of the transfusion?		 No
Have you ever received pituitary-derived human growth hormone?
If yes, what year?		 No
Have you been diagnosed with hemophilia or a related clotting disorder and received human derived clotting factor concentrates (non-viral inactivated Factor VIII or Factor IX concentrate)?
If yes, what year?		 No

Please indicate whether you currently have, have had in the past, or have ever been treated for:
QuestionResponse
Hydrocele No
Syphilis No
Blood transfusion No
Prolonged fever No
Herpes No
Fever above 101 F (in the past 3 months) No
Hepatitis B, C, other No
Orchitis No
Genital Warts/Papillomavirus No
Epididymitis No
Liver disease No
Prostatitis No
Renal disease No
Mumps w/testes involved No
Diabetes No
Urethritis No
Psychiatric disorders No
Varicocele No
Undescended testicle No
AIDS No
Tuberculosis No
Alzheimer's disease No
Multiple sclerosis No
Creutzfeldt-Jacob disease (CJD or vCJD) No
Note any comments regarding above items: N/A

Indicate conditions occurring now or in the past:
QuestionResponse
rashes, color change No
frequent urinating No
itching No
waking to urinate
# of times / night:		 No
warts, moles No
cancer No
eczema, lumps, hives No
sores or discharge No
very dry skin No
bleeding or bruising No
excessive sweating No
trouble swallowing No
minor injury No
poor appetite No
anemia No
gas, cramps, pains No
lymph node or gland swelling No
heartburn, indigestion No
ear trouble, infection No
nausea, vomiting, constipation, diarrhea No
blood in stool or black stool No
hearing loss, ringing in ear No
yellow jaudice, hepatitis B or C No
eye problems No
hemorrhoids No
nosebleeds No
hernia No
sore throats No
gall bladder problems No
stuffy nose, sinus trouble, hay fever No
pains in joints, arthritis No
high blood pressure No
swollen joints No
hoarseness No
back pain, neck pain No
dental or gum problems No
head injury, concussion No
enlarged or painful breasts No
headaches No
breast lumps No
dizziness, fainting No
discharge from nipples No
convulsions, seizures, fits No
shortness of breath No
shaking, tremor No
cough, chest colds No
weakness, paralysis No
bringing up sputum with blood No
numbness, tingling No
wheezing, asthma No
difficulty walking, coordination No
chest pain, pleurisy No
poor circulation, varicose veins No
TB or exposure to TB No
depression, anxiety No
fevers, sweats, chills No
poor sleeping No
pneumonia No
nervousness, tension No
fast or irregular heartbeat No
trouble thinking, remembering No
chest pain, tightness, pressure No
crying, upset, worrying No
trouble breathing when lying down No
sexual problems No
waking short of breath No
goiter, thyroid problems No
swelling of feet or ankles No
blood clots No
previous heart trouble No
murmurs or rheumatic fever No
CMV IgG AntibodyPositive
CMV IgM AntibodyNegative
Any other comments N/A

Family Medical History

Complete for each of the following relatives. List all specific health problems, operations, and/or causes of death (include stillborns, infant deaths and childhood deaths) for each individual.

Your Mother
QuestionResponseComment/Age Affected
 Current age or age at death    56 
 Health Problem
 Thyroid problems - on medication, overweight 50
 Living / Dead Living  

Your Father
QuestionResponseComment/Age Affected
 Current age or age at death    56 
 Health Problem
 Arthritis 40
 Living / Dead Living  

Brother(s)

Your Brother 1
QuestionResponseComment/Age Affected
 Current age or age at death    30 
 Health Problem
 Healthy 
 Living / Dead Living  

Sister(s)

Your Sister 1
QuestionResponseComment/Age Affected
 Current age or age at death    28 
 Health Problem
 Healthy 
 Living / Dead Living  

Your Mother's Father
QuestionResponseComment/Age Affected
 Current age or age at death    65 
 Health Problem
 Sudden heart attack 65
 Living / Dead Dead  

Your Mother's Mother
QuestionResponseComment/Age Affected
 Current age or age at death    79 
 Health Problem
 Cataracts 70
 Arthritis 50
 Living / Dead Living  

Your Mother's Sisters 1
QuestionResponseComment/Age Affected
 Current age or age at death    48 
 Health Problem
 Healthy 
 Living / Dead Living  

Your Mother's Sisters 2
QuestionResponseComment/Age Affected
 Current age or age at death    50 
 Health Problem
 Healthy 
 Living / Dead Living  

Your Mother's Brothers 1
QuestionResponseComment/Age Affected
 Current age or age at death    60 
 Health Problem
 Healthy 
 Living / Dead Living  

Your Father's Father
QuestionResponseComment/Age Affected
 Current age or age at death    68 
 Health Problem
 Died after a fall down stairs 
 Living / Dead Dead  

Your Father's Mother
QuestionResponseComment/Age Affected
 Current age or age at death    50 
 Health Problem
 Was an amputee, cause of death due to complications 
 Living / Dead Dead  

Your Father's Sisters 1
QuestionResponseComment/Age Affected
 Current age or age at death    62 
 Health Problem
 Healthy 
 Living / Dead Living