Fairfax Cryobank |
Donor 2700 Medical Profile |
Questions |
Personal Behavior History |
Donor Genetic History |
Donor Medical History |
Family Medical History |
Personal Behavior History | ||
Question | Response | |
Alcohol use: If yes, oz./week and type of alcohol: | Occasionally - 0-24 oz/week of beer or wine | |
Do you or any of your relatives have a history of alcoholism or alcohol abuse? 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? | 0 | |
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 | |
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? | No | |
Another man anal or oral, even once, since 1977? | No | |
A person having intravenous, intramuscular, or subcutaneous injection of drugs not prescribed by a licensed physician for medical purposes? | No |
Have you: | ||
Question | Response |
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 at least 97 mutations | |
Have you been tested for Alpha-1 Antitrypsin Disorder? If yes, the result: | No | |
Have you had any additional genetic testing? If yes, complete the following: | Yes - Karyotype | |
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: If yes, result(s): | N/A | |
Niemann-Pick: 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 | |
BRCA1/BRCA2 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? | No | |
If yes, have you been tested as a carrier of thalassemia? | Yes - Standard donor screening | |
If yes, result: | Non Carrier |
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 | None |
|
Congenital heart disease | None |
|
Hemophilia/bleeding problem | None |
|
Severe bleeding tendency | None |
|
Cystic Fibrosis | None |
|
Alpha-1 Antitrypsin Disorder | None |
|
Pyloric stenosis | None |
|
Inflammatory bowel disease | None |
|
Diabetes mellitus requiring insulin therapy. | None |
|
Diabetes mellitus not requiring insulin therapy. | None |
|
PKU or inherited metabolism disorder | None |
|
Progressive kidney disease | None |
|
Polycystic kidney disease | None |
|
Miscarriages or stillborn | None |
|
Herpes simplex virus, genital | None |
|
Migraines | None |
|
Mental retardation | None |
|
Senility or mental deterioration before age 60 | None |
|
Epilepsy/seizures | None |
|
Neural tube defects - open spine or hypocephalus/water on the brain | None |
|
Huntington's disease | None |
|
Tuberous sclerosis | None |
|
Neurofibromatosis | None |
|
Parkinson's disease | None |
|
Down's syndrome/Mongolism | None |
|
Autism | None |
|
Autism Spectrum Disorder | None |
|
PDD (pervasive developmental delay) | None |
|
Asperger's Syndrome | None |
|
Schizophrenia | None |
|
Manic depressive psychosis | None |
|
Muscular dystrophy | None |
|
Loss of muscle coordination | None |
|
Rheumatoid arthritis | None |
|
Reiter's disease | None |
|
Club foot | None |
|
Deafness before age of 60 | None |
|
Cataracts before age of 60 | None |
|
Blindness in both eyes before age of 60 | None |
|
Glaucoma | None |
|
Psoriasis | None |
|
Albinism | None |
|
More than 5 purple or coffee-colored spots on the skin (size of a quarter or larger) | None |
|
Drug abuse, misuse, or addiction | None |
|
Cleft palate or cleft lip | None |
|
Serious birth defects | None |
|
Inguinal hernia | None |
|
Premature degeneration of any organ system | None |
|
The same cancer in more than one family member | None |
Donor Medical History | ||
Question | Response | |
List any operations: Age & reason: | None | |
Hospitalization other than surgery: Age & type of illness: | None | |
Have you ever had any broken bones? If yes, please give age and description: | Yes - Left 4th metacarpal (hand): Football injury | |
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: | 0 | |
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: | Alleve (as needed, 1/day): Sprains/strains; Sudafed and zyrtec (in the fall, once/week): Allergies | |
List all current medication or treatments (include vitamins, aspirin, antacids, laxatives, herbal, sports supplements, etc.) Include drug, frequency and duration taken, and reason: | Alleve (as needed, 1/day): Sprains/strains; Sudafed and zyrtec (in the fall, once/week): Allergies | |
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 - Pollen: Itchy skin and sneezing | |
Have you been exposed to, or been at risk of exposure to: radiation, chemicals, or toxic amounts of lead, mercury, or gold? If yes, please describe: | No | |
Have you been permanently excluded or deferred from donating blood or plasma? If yes, when and why? | No | |
Have you been tested for HIV (AIDS)? If yes, when: | Yes - Negative, ongoing donor screening | |
Sexual orientation: | Heterosexual | |
Number of current sexual partners: | 1 | |
Have you had a partner who has had cultures of Trichomonas? 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 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 |
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 MotherQuestion | Response | Comment/Age Affected | Current age or age at death | 59 | | Health Problem |
Living / Dead | Living | |
|
Your FatherQuestion | Response | Comment/Age Affected | Current age or age at death | 57 | | Health Problem |
Living / Dead | Living | |
|
Sister(s) |
Your Sister 1Question | Response | Comment/Age Affected | Current age or age at death | 21 | | Health Problem |
Living / Dead | Living | |
|
Son(s) |
Your Son 1Question | Response | Comment/Age Affected | Current age or age at death | 12 | | Health Problem |
Living / Dead | Living | |
|
Daughter(s) |
Your Daughter 1Question | Response | Comment/Age Affected | Current age or age at death | 9 | | Health Problem |
Living / Dead | Living | | |
Your Daughter 2Question | Response | Comment/Age Affected | Current age or age at death | 2.5 | | Health Problem |
Living / Dead | Living | |
|
Your Mother's FatherQuestion | Response | Comment/Age Affected | Current age or age at death | 80 | | Health Problem |
Living / Dead | Dead | |
|
Your Mother's MotherQuestion | Response | Comment/Age Affected | Current age or age at death | 83 | | Health Problem |
Living / Dead | Living | |
|
Your Father's FatherQuestion | Response | Comment/Age Affected | Current age or age at death | 84 | | Health Problem |
Living / Dead | Dead | |
|