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Personal Behavior History

Question Response
Current alcohol use:
If yes, oz./week and type of alcohol:
Regularly - 36 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
If you did smoke but quit, when did you last smoke?N/A
For how many years?0
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?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
Question Response
Are you of Jewish ancestry?
If yes, please note: Ashkenazi, Sephardi, or Other
No
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
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?No
If yes, have you been tested as a carrier of beta thalassemia?Yes - Standard donor screening
If yes, result:Non Carrier
Heart attackNone
Congenital heart diseaseNone
Hemophilia/bleeding problemNone
EmphysemaNone
Cystic FibrosisNone
Alpha-1 Antitrypsin DeficiencyNone
Pyloric stenosisNone
Colon cancerN/A
Inflammatory bowel diseaseNone
Irritable Bowel SyndromeN/A
Diabetes mellitus requiring insulin therapyNone
Diabetes mellitus not requiring insulin therapyNone
PKU or inherited metabolism disorderNone
Progressive kidney diseaseNone
Polycystic kidney diseaseNone
Miscarriages or stillbornNone
Herpes simplex virus, genitalNone
MigrainesNone
Mental retardationNone
Senility or mental deterioration before age 60None
Epilepsy/seizuresNone
Neural tube defects - open spine or hydrocephalus/water on the brainNone
Huntington's diseaseNone
Tuberous sclerosisNone
NeurofibromatosisNone
Parkinson's diseaseAunt/Uncle - Paternal uncle #3, age 67
Down SyndromeNone
AutismN/A
Autism Spectrum DisorderN/A
Pervasive Developmental Delay (PDD)N/A
Asperger's SyndromeN/A
SchizophreniaNone
Bipolar (manic depressive psychosis)None
Attention Deficit Disorder (ADD)N/A
Attention Deficit Hyperactivity Disorder (ADHD)N/A
Muscular DystrophyNone
Loss of muscle coordinationNone
Rheumatoid ArthritisGrandparent - Maternal grandmother, age unknown
Reiter's DiseaseNone
Club footNone
Deafness before age of 60None
Cataracts before age of 60None
Blindness in both eyes before age of 60None
GlaucomaGrandparent - Maternal grandmother, age 60
Macular DegenerationN/A
AcneNone
PsoriasisNone
AlbinismNone
More than 5 purple or coffee-colored spots on the skin-1.5 cm (1/2 inch) or largerNone
Drug abuse, misuse, or addictionNone
Cleft palate or cleft lipNone
Serious birth defectsNone
Inguinal herniaNone
Premature degeneration of any organ systemNone
The same cancer in more than one family memberNone

Donor Medical History

Question Response
List any operations:
Age & reason:
Wisdom teeth, 15 years ago
Hospitalization other than surgery:
Age & type of illness:
N/A
Have you ever had any broken bones?
If yes, please give age and description:
Yes - Fractured wrist, age 12
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:
1 - Flu-like symptoms last winter
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:Multiivitamin, Enzyte; both taken for general health; Nyquil Cold & Flu medicine
List all current medication or treatments (include vitamins, aspirin, antacids, laxatives, herbal, sports supplements, etc.) Include drug, frequency and duration taken, and reason:Multiivitamin, Enzyte; both taken for general health
Do you wear glasses or contact lenses?
Are you near or far-sighted?
No
Usual weight?230
Recent weight loss or gain?
# of lbs and reason:
Yes - 15 lbs. due to training for a triathlon
Allergies (medicines, food, pollens)?
If yes, please list substance and reaction caused:
No
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?0
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

Family Medical History
Ver lista de perguntas. here

Question Response Comment/Age Affected
Current age or age at death 66
Health Problem Healthy 
Living / DeadLiving
Question Response Comment/Age Affected
Current age or age at death 71
Health Problem High blood pressure50
Colon cancer67
Stroke68
Living / DeadLiving
Question Response Comment/Age Affected
Current age or age at death 43
Health Problem Healthy 
Living / DeadLiving
Question Response Comment/Age Affected
Current age or age at death 41
Health Problem Healthy 
Living / DeadLiving
Question Response Comment/Age Affected
Current age or age at death 38
Health Problem Healthy 
Living / DeadLiving
Question Response Comment/Age Affected
Current age or age at death 33
Health Problem Peripheral vision impaired from unknown cause while in South Africa25
Small seizure30
Living / DeadLiving
Question Response Comment/Age Affected
Current age or age at death 9
Health Problem Healthy 
Living / DeadLiving
Question Response Comment/Age Affected
Current age or age at death 74
Health Problem Bladder cancer 65
Possible heart attack74
Living / DeadDead
Question Response Comment/Age Affected
Current age or age at death 76
Health Problem Arthritis, age of onset unknown 
Gallbladder removed, age unknown 
Glaucoma60
Living / DeadDead
Question Response Comment/Age Affected
Current age or age at death 65
Health Problem Healthy 
Living / DeadLiving
Question Response Comment/Age Affected
Current age or age at death 59
Health Problem Healthy 
Living / DeadLiving
Question Response Comment/Age Affected
Current age or age at death 56
Health Problem Back problems, age unknown (accident related) 
Living / DeadLiving
Question Response Comment/Age Affected
Current age or age at death 68
Health Problem Bone cancer68
Living / DeadDead
Question Response Comment/Age Affected
Current age or age at death 68
Health Problem Lymphoma67
Living / DeadDead
Question Response Comment/Age Affected
Current age or age at death 85
Health Problem Healthy 
Living / DeadLiving
Question Response Comment/Age Affected
Current age or age at death 64
Health Problem Possible heart problems64
Living / DeadDead
Question Response Comment/Age Affected
Current age or age at death 76
Health Problem Healthy 
Living / DeadLiving
Question Response Comment/Age Affected
Current age or age at death 74
Health Problem Healthy 
Living / DeadLiving
Question Response Comment/Age Affected
Current age or age at death 70
Health Problem Parkinson's67
Living / DeadDead