Doador 4011 - Medical Profile

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Personal Behavior History

Question	Response
Current alcohol use: If yes, oz./week and type of alcohol:	Occasionally - 12-24 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
If you did smoke but quit, when did you last smoke?	Never
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

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

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 97 mutations tested
Karyotype? If yes, the result:	Yes - Normal karyotype
Spinal Muscular Atrophy (SMA)? If yes, the result:	Non Carrier - Standard donor screening
Tay Sachs? If yes, the result:	Non Carrier - by DNA and enzyme analysis

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?	No
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	None
Congenital heart disease	None
Hemophilia/bleeding problem	None
Emphysema	None
Cystic Fibrosis	None
Alpha-1 Antitrypsin Deficiency	None
Pyloric stenosis	None
Colon cancer	N/A
Inflammatory bowel disease	None
Irritable Bowel Syndrome	N/A
Diabetes mellitus requiring insulin therapy	None
Diabetes mellitus not requiring insulin therapy	Aunt/Uncle - Maternal uncle, age 50
PKU or inherited metabolism disorder	None
Progressive kidney disease	None
Polycystic kidney disease	None
Miscarriages or stillborn	Mother - age 35
Herpes simplex virus, genital	None
Migraines	Sibling - Brother #2, age 48
Mental retardation	None
Senility or mental deterioration before age 60	None
Epilepsy/seizures	None
Neural tube defects - open spine or hydrocephalus/water on the brain	None
Huntington's disease	None
Tuberous sclerosis	None
Neurofibromatosis	None
Parkinson's disease	None
Down Syndrome	None
Autism	None
Autism Spectrum Disorder	None
Pervasive Developmental Delay (PDD)	None
Asperger's Syndrome	None
Schizophrenia	None
Bipolar (manic depressive psychosis)	None
Attention Deficit Disorder (ADD)	N/A
Attention Deficit Hyperactivity Disorder (ADHD)	N/A
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	Grandparent - Maternal grandmother, age 80
Macular Degeneration	N/A
Acne	Self
Psoriasis	None
Albinism	None
More than 5 purple or coffee-colored spots on the skin-1.5 cm (1/2 inch) 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:	Appendix removed due to infection in 2002
Hospitalization other than surgery: Age & type of illness:	Brief hospital stay (did not stay overnight) due to dislocated patella (knee cap) in 1998
Have you ever had any broken bones? If yes, please give age and description:	Yes - Right leg and arm broken as a result of a fall as a baby; Right arm from fall in first grade; Left arm in Jr. High from fall from speeding car; Rib from a skateboard accident in Jr.High; Pinky caught in swing
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
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:	Multivitamin and vitamin supplement taken daily for general health; Antibiotics (Z-Pack) taken daily for five days to treat the flu; Doryx taken daily for four weeks due to a skin infection
List all current medication or treatments (include vitamins, aspirin, antacids, laxatives, herbal, sports supplements, etc.) Include drug, frequency and duration taken, and reason:	Multivitamin taken daily for general health
Do you wear glasses or contact lenses? Are you near or far-sighted?	No
Usual weight?	217
Recent weight loss or gain? # of lbs and reason:	No
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?	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?	No

Family Medical History
Ver lista de perguntas. here

Your Mother

Question	Response	Comment/Age Affected
Current age or age at death	71
Health Problem	Miscarriage	35
	Osteoporosis, controlled with medication	50
	Gallstones, treated by removing gall bladder	60
	Bell's palsy, no medication or treatment received	71
Living / Dead	Living

Your Father

Question	Response	Comment/Age Affected
Current age or age at death	75
Health Problem	Hearing impaired due to occupational noise levels, corrected by wearing a hearing aid	58
	Mitral valve fibrillation due to sleep apnea, cpap machine at night, pacemaker installed at age 74	69
	Broken arm and hurt back, twisted knee due to falling. Exploratory surgery for knee	74
	Transient ischemic attack after exploratory surgery, no treatment	74
Living / Dead	Living

Brothers

Your Brother 1

Question	Response	Comment/Age Affected
Current age or age at death	52
Health Problem	Asthma during childhood, no medication or treatment received	10
	Hay fever during childhood, no medication or treatment received	10
	Broken shoulder due to fall from treadmill, treated successfully with surgery	52
Living / Dead	Living

Your Brother 2

Question	Response	Comment/Age Affected
Current age or age at death	50
Health Problem	Migraines, no medication or treatment received	48
Living / Dead	Living

Your Brother 3

Question	Response	Comment/Age Affected
Current age or age at death	46
Health Problem	Healthy
Living / Dead	Living

Your Brother 4

Question	Response	Comment/Age Affected
Current age or age at death	38
Health Problem	Mild digestive problems, diarrhea during childhood, no medication or treatment received	14
Health Problem	Deviated septum, corrected with surgery	33
Living / Dead	Living

Sisters

Your Sister 1

Question	Response	Comment/Age Affected
Current age or age at death	42
Health Problem	Healthy
Living / Dead	Living

Sons

Your Son 1

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

Your Son 2

Question	Response	Comment/Age Affected
Current age or age at death	0.2
Health Problem	Healthy (newborn)
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	48
Health Problem	Brain tumor due to occupational exposure while working in a mine, attempted treatment with surgery	48
	Brain swelling resulting from surgery to remove tumor, part of skull removed to drain excess fluid	48
	Cause of death: Brain tumor	48
Living / Dead	Dead

Your Mother's Mother

Question	Response	Comment/Age Affected
Current age or age at death	93
Health Problem	Hysterectomy due to unknown infection	30
	High blood pressure, treated with medication	70
	Glaucoma, treated with medication	80
	Heart disease, treated with blood thinners	90
	Cause of death: Pneumonia	93
Living / Dead	Dead

Your Mother's Brothers 1

Question	Response	Comment/Age Affected
Current age or age at death	68
Health Problem	Diabetes not requiring insulin therapy	50
Health Problem	Cause of death: Automobile accident	68
Living / Dead	Dead

Your Father's Father

Question	Response	Comment/Age Affected
Current age or age at death	93
Health Problem	Mitral valve fibrillation due to sleep apnea, no treatment or medication	69
Health Problem	Cause of death: Stroke	93
Living / Dead	Dead

Your Father's Mother

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

Your Father's Sisters 1

Question	Response	Comment/Age Affected
Current age or age at death	65
Health Problem	Healthy
Living / Dead	Living

Your Father's Brothers 1

Question	Response	Comment/Age Affected
Current age or age at death	69
Health Problem	Healthy
Living / Dead	Living

Número do Doador: 4011

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