Do you or any member of your family have any of the following? |
QUESTION |
RESPONSE |
RELATION AND AGE AFFECTED |
Down's Syndrome (Mongolism) |
No |
|
club foot |
No |
|
cleft lip or cleft palate |
No |
|
congenital heart disease |
No |
|
pyloric stenosis |
No |
|
neural tube defects (open spine or water on the brain) |
No |
|
PKU or inherited metabolic disorder |
No |
|
progressive kidney disease |
No |
|
polycystic kidney disease |
No |
|
diabetes mellitus not requiring insulin therapy |
No |
|
diabetes mellitus requiring insulin therapy |
No |
|
premature degeneration of any organ system |
No |
|
cataracts before age 40 |
No |
|
deafness before age 60 |
No |
|
blindness in both eyes before age 60 |
No |
|
loss of muscle coordination |
No |
|
muscular dystrophy |
No |
|
schizophrenia |
No |
|
manic depressive psychosis |
No |
|
mental deterioration or senility before age 60 |
No |
|
mental retardation |
No |
|
epilepsy or seizure disorder |
No |
|
alpha-1 antitrypsin disorder |
No
|
|
Parkinson's disease |
No |
|
rheumatoid arthritis |
No |
|
hemophilia |
No |
|
psoriasis |
No |
|
drug abuse problem |
No |
|
migraines |
No |
|
glaucoma |
No |
|
genital herpes simplex virus |
No |
|
inguinal hernia |
No |
|
heritable birth defects |
No |
|
Huntington's disease |
No |
|
two or more miscarriages or stillborn |
No |
|
tuberous sclerosis |
No |
|
neurofibromatosis |
No |
|
more than five coffee-colored spots on the skin (size of a quarter or larger) or numerous lumps under the skin |
No |
|
heart attack (less than 50) or has a relative died early |
Yes |
Aunt - car accident at age 40 |
cystic fibrosis |
No |
|
same cancer in more than one family member |
No |
|
servere bleeding tendency |
No |
|
albinism |
No
|
|
Reiter's disease |
No
|
|
inflammatory bowel disease |
No
|
|
Other Questions |
QUESTION |
RESPONSE |
COMMENTS |
Alcohol use? If yes, how much? |
Occasionally |
4 beers a week |
Any relatives with alcoholism? If yes, who? |
No |
|
Tobacco use? If yes, # of packs/day, date quit, for how many years. |
No |
|
Have you had sex with another man in the preceding 5 years? |
No
|
|
Have you had sex with a person having non-medical intravenous, intramuscular, or subcutaneous injection of drugs in the preceding 5 years? |
No
|
|
Have you had sex with a person who has engaged in sex in exchange for money or drugs in the preceding 5 years? |
No
|
|
Have you had sex with a person who has had sex with another person described in any of the above in the preceding 12 months? |
No
|
|
Have you ever been convicted of a felony? If yes, explain. |
No
|
|
Do you sleep well? |
Yes |
|
Do you exercise on a regular basis? |
Yes |
|
Is your diet well balanced? Explain if needed. |
Yes |
|
Any dietary restrictions? Explain. |
No |
|
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
|
|
Were you born with any birth defects (heart defect, cleft lip or palate, club feet, other)? If yes, please explain. |
No
|
|
Are there any known genetic conditions or birth defects in your family? If yes, please explain. |
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 |
Are you of Jewish ancestry? |
No |
|
Have you been tested for BRCA -1( breast and ovarian cancer)? If yes, the result? |
|
N/A |
Have you been tested as a carrier for Tay Sachs? If yes, the result. |
|
N/A |
Have you been tested as a carrier for Gaucher? If yes, the results. |
|
N/A |
Have you been tested as a carrier for Canavan? If yes, the results. |
|
N/A |
Are you of African ancestry? |
No |
|
Have you been tested as a carrier for Sickle Cell disease? If yes, the results. |
|
N/A |
Are you of Mediterranean (Greek or Italian) ancestry? |
No |
|
Have you been tested as a carrier of thalassemia? If yes, result? |
Yes |
During the donor screening process - non-carrier |
Have you had any operations? If yes, type and year: |
Yes |
Screw put into foot following 2 breaks, 10 years ago |
Have you been hospitalized other than for surgery? If yes, year and type and illness: |
No |
|
Have you ever had any broken bones? If yes, please describe: |
Yes |
Foot broken twice playing professional baseball |
Have you ever had any serious illnesses? If yes, please explain: |
No |
|
Are you presently under a physician's care for any reason? If yes, please describe: |
No |
|
Have you ever had occupational exposure to radiation or chemicals? If yes, please describe: |
No
|
|
List all drugs, prescription, non-prescription, & "recreational" you have taken in the past 12 months. If yes, type, how often and reason: |
|
None |
List all current medications or treatments (include vitamins, aspirin, antacids, laxatives, etc.) If yes, type, how often and reason: |
|
None |
How many days in the past 12 months could you not work because of all illness (colds, flu, accidents, surgery, etc.)? |
|
Zero |
Do you wear glasses or contact lenses? |
No |
|
Usual weight? |
|
220 |
Recent weight loss or gain? If yes, how much? |
No |
|
Allergies (medicines, food, pollens)? If yes, list kind: |
Yes |
Possible - minor reactions to vinegar |
Have you ever been refused as blood donor? If yes, why? |
No
|
|
Have you been tested for HIV (AIDS) prior to applying to this program? If yes, when, the results and the reason for testing: |
Yes |
6 months ago - blood donation |
Sexual preference: |
Heterosexual |
|
Number of current sexual partners: |
1 |
|
Has any sexual partner been positive for HIV (AIDS)? If yes, explain: |
No
|
|
Has any sexual partner had an episode of trichomoniasis? If yes, explain? |
No
|
|
Do you have AIDS? |
No |
|
Do you have Alzheimer's disease? |
No
|
|
Have you ever had a tattoo? If yes, what year did you get the tattoo? |
No
|
|
Have you ever had your 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 transfusion? |
No
|
|
Have you ever received pituitary-derived human growth hormone? If yes, what year? |
No
|
|
Have you ever received factor VIII or Factor IX concentrate? If yes, what year? |
No
|
|