Doador 2215 - Medical Profile

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Personal Behavior History

Question	Response
Current alcohol use: If yes, oz./week and type of alcohol:	Frequently - 24 oz. beer/week
Have you or any of your family members been diagnosed with alcoholism or drug addiction? If yes, relation and age affected:	No
Tobacco use: Do you smoke? If yes, #/day and for how long:	No - Occasional cigar
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?	N/A
Any dietary restrictions? If yes, explain:	No

Sexual History

Have you ever had sex with:

Question	Response
A partner whose sexual background you are unsure of in the past 12 months?	N/A
Another man anal or oral, even once, since 1977?	No

Donor Genetic History

Question	Response
Were you or any family members born with any birth defects? If yes, explain:	No
Have you been tested for Cystic Fibrosis? If yes, the result:	Yes - Non-carrier for the 86 mutations tested
Karyotype? If yes, the result:	Yes - Normal karyotype
Spinal Muscular Atrophy (SMA)? If yes, the result:	Unknown - Donor was not tested
Tay Sachs? If yes, the result:	Unknown - Donor was not tested

Ancestry

Question	Response
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?

Question	Response
Tay Sachs: If yes, result(s):	N/A
Gaucher: If yes, result(s):	N/A
Canavan: If yes, result(s):	N/A
Fanconi Anemia Type C: If yes, result(s):	N/A
Niemann-Pick Type A: If yes, result(s):	N/A
Bloom Syndrome: If yes, result(s):	N/A
Familial Dysautonomia: If yes, result(s):	N/A
Mucolipidosis IV: If yes, result(s):	N/A
Maple Syrup Urine Disease 1B: If yes, result(s):	N/A
Usher Syndrome III & 1F: If yes, result(s):	N/A
Glycogen Storage Disease 1A: If yes, result(s):	N/A
ABCC8-Related Hyperinsulinism: If yes, result(s):	N/A
BRCA1/BRCA2: If yes, result(s):	N/A
Lipoamide Dehydrogenase Deficiency: If yes, result(s):	N/A

Ancestry

Question	Response
Are you of African ancestry?	No
If yes, have you been tested as a carrier of sickle cell anemia?	Yes - Standard donor screening
If yes, result:	Non Carrier
Are you of Mediterranean, Greek or Italian ancestry?	Yes
If yes, have you been tested as a carrier of beta thalassemia?	Yes - Standard donor screening
If yes, result:	Non Carrier

Have you or any member of your family had, currently have or been diagnosed with any of the following conditions? If yes, please list the affected individual(s), mother or father's side, age at onset, treatment and any other pertinent information.

Heart attack	Grandparent - Maternal grandfather, age 76
Congenital heart disease	No
Hemophilia/bleeding problem	No
Emphysema	N/A
Cystic Fibrosis	No
Alpha-1 Antitrypsin Deficiency	No
Pyloric stenosis	No
Colon cancer	N/A
Inflammatory bowel disease	No
Irritable Bowel Syndrome	N/A
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 hydrocephalus/water on the brain	No
Huntington's disease	No
Tuberous sclerosis	No
Neurofibromatosis	No
Parkinson's disease	No
Down Syndrome	No
Autism	N/A
Autism Spectrum Disorder	N/A
Pervasive Developmental Delay (PDD)	N/A
Asperger's Syndrome	N/A
Schizophrenia	No
Bipolar (manic depressive psychosis)	No
Attention Deficit Disorder (ADD)	N/A
Attention Deficit Hyperactivity Disorder (ADHD)	N/A
Muscular Dystrophy	No
Loss of muscle coordination	No
Rheumatoid Arthritis	No
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
Macular Degeneration	N/A
Acne	N/A
Psoriasis	No
Albinism	No
More than 5 purple or coffee-colored spots on the skin-1.5 cm (1/2 inch) 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

Question	Response
List any operations: Age & reason:	Complete ACL/MCL reconstruction of knee 7 years ago (sports related); Wisdom teeth removed 4 years ago
Hospitalization other than surgery: Age & type of illness:	No
Have you ever had any broken bones? If yes, please give age and description:	Yes - Fibula 7 years ago (sports related)
Have you ever had any serious illnesses? If yes, please give age and description:	No
How many days in the past 12 months could you not work because of all illness (colds, flu, accidents, surgery, etc)? Please describe:
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:	Aleve, taken 3-4 times for headache; Sports protein drinks after heavy exercise for nutritional supplementation
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?	195
Recent weight loss or gain? # of lbs and reason:	No
Allergies (medicines, food, pollens)? If yes, please list substance and reaction caused:	Yes - Penicillin
Have you been tested for HIV (AIDS)? If yes, when:	Yes - Negative, ongoing donor screening
Sexual orientation:	Heterosexual
How many sexual partners do you currently have?	1
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?	Yes - Ear, 15 years ago

Family Medical History
Ver lista de perguntas. here

Your Mother

Question	Response	Comment/Age Affected
Current age or age at death	71
Health Problem	Healthy
Living / Dead	Living

Your Father

Question	Response	Comment/Age Affected
Current age or age at death	75
Health Problem	Liver cancer	71
Living / Dead	Dead

Sisters

Your Sister 1

Question	Response	Comment/Age Affected
Current age or age at death	48
Health Problem	Healthy
Living / Dead	Living

Daughters

Your Daughter 1

Question	Response	Comment/Age Affected
Current age or age at death	1
Health Problem	Healthy
Living / Dead	Living

Your Mother's Father

Question	Response	Comment/Age Affected
Current age or age at death	76
Health Problem	Heart attack	76
Living / Dead	Dead

Your Mother's Mother

Question	Response	Comment/Age Affected
Current age or age at death	48
Health Problem	Rectal cancer	48
Living / Dead	Dead

Your Mother's Sisters 1

Question	Response	Comment/Age Affected
Current age or age at death	68
Health Problem	Healthy
Living / Dead	Living

Your Mother's Sisters 2

Question	Response	Comment/Age Affected
Current age or age at death	64
Health Problem	Healthy
Living / Dead	Living

Your Mother's Brothers 1

Question	Response	Comment/Age Affected
Current age or age at death	67
Health Problem	Healthy
Living / Dead	Living

Your Father's Father

Question	Response	Comment/Age Affected
Current age or age at death	78
Health Problem	Stroke	78
Living / Dead	Dead

Your Father's Mother

Question	Response	Comment/Age Affected
Current age or age at death	80
Health Problem	Unknown cause of death	80
Living / Dead	Dead

Your Father's Sisters 1

Question	Response	Comment/Age Affected
Current age or age at death	50
Health Problem	Brain cancer	50
Living / Dead	Dead

Your Father's Brothers 1

Question	Response	Comment/Age Affected
Current age or age at death	50
Health Problem	Stroke	50
Living / Dead	Dead

Your Father's Brothers 2

Question	Response	Comment/Age Affected
Current age or age at death	76
Health Problem	Healthy
Living / Dead	Living

Número do Doador: 2215

Personal Behavior History

Sexual History

Donor Genetic History

Donor Medical History

Family Medical HistoryVer lista de perguntas. here

Family Medical History
Ver lista de perguntas. here