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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 HistoryVer 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 |
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 |
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 |
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 |