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Fairfax Cryobank

Donor 2190 Medical Profile

Questions

Do you or any member of your family have any of the following?

Have you ever had?

Have you experienced the following condition(s) on a regular basis?

Have you had the following condition(s) now or in the past?

Other Questions

Family History

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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

Have you ever had?
QUESTION	RESPONSE
syphilis	No
genital herpes	No
hepatitis B,C, other	No
orchitis	No
epididymitis	No
prostatis	No
mumps with testes involved	No
urethritis	No
varicocele	No
Creutzfeldt-Jacob disease	No
hydrocele	No
blood transfusion	No
prolonged fever	No
fever above 101 degrees (in the past three months)	No
genital warts/papillomavirus	No
liver disease	No
renal disease	No
diabetes	No
psychiatric disorders	No
undescended testicle	No
tuberculosis	No
multiple sclerosis	No

Have you experienced the following condition(s) on a regular basis?
QUESTION	RESPONSE	COMMENTS
rashes, color change	No
itching	No
excessive sweating	No
minor injury	No
lymp node or gland swelling	No
ear trouble, infection	No
nosebleeds	No
stuffy nose, sinus trouble, hay fever	No
sore throats	No
hoarseness	No
dental or gum problems	No
shortness of breath	No
cough, chest colds	Yes	Normal colds once or twice a year
bringing up sputum with blood	No
fever, sweats, chills	No
fast or irregular heartbeat	No
frequent urinating	No
waking to urinate (#times / night)	No
sores or discharge	No
bleeding or bruising	No
trouble swallowing	No
poor appetite	No
gas, cramps, pain	No
heartburn, indigestion	No
nausea, vomiting, constipation, diarrhea	No
back pain, neck pain	No
headaches	No
poor sleeping	No
nervousness, tension	No
trouble thinking, remembering	No
crying, upset, worrying	No

Have you had the following condition(s) now or in the past?
QUESTION	RESPONSE
warts, moles	No
eczema, lumps, hives	No
very dry skin	No
anemia	No
hearing loss, ringing in ear	No
eyes problems	No
enlarged or painful breasts	No
breasts lumps	No
discharge from nipples	No
wheezing, asthma	No
chest pain, pleurisy	No
TB or exposure to TB	No
pneumonia	No
chest pain, tightness, pressure	No
trouble breathing when lying down	No
waking short of breath	No
swelling of feet or ankles	No
previous heart trouble	No
murmurs or rheumatic fever	No
high blood pressure	No
poor circulation, varicose veins	No
blood clots	No
blood in stool or black stool	No
yellow jaundice, hepatitis	No
hemorrhoids	No
hernia	No
gall bladder problems	No
pains in joints, arthritis	No
swollen joints	No
head injury, concussion	Yes - concussion (raquetball)
convulsions, seizures, fits	No
shaking, tremor	No
weakness, paralysis	No
numbness, tingling	No
difficulty walking, coordination	No
depression, anxiety	No
sexual problems	No
cancer	No
diabetes	No
goiter, thyroid problems	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

Family History
FAMILY MEMBER	AGE/AGE OF DEATH	HEALTH PROBLEMS	AGE DIAGNOSED	LIVING/DEAD
Mother	61	Healthy		L
Father	62	Healthy		L
Brother(s)	37	Tonsils removed	15	L
	30	Appendicitis	28	L
Mother's Father	83	Heart failure	83	D
		Alzheimer's	81
Mother's Mother	89	Healthy - in nursing home		L
Mother's Sister(s)	64	Healthy		L
	40	None - car accident		D
Mother's Brother(s)	56	Healthy		L
Father's Father	84	Heart failure		D
Father's Mother	92	Healthy - in nursing home		L
Father's Brother(s)	65	Healthy		L