Cryogenic Laboratories, Inc. |
Donor 2281 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 alchohol: | Occasionally - 24 oz a week | |
Any relatives with alcoholism? If yes, relation and age affected: | Yes - Paternal grandfather at age 50 | |
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 - N/A | |
For how many years? | 0 - N/A | |
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 | |
Another man anal or oral, even once, since 1977? | No | |
A person having non-medical intravenous, intramuscular, or subcutaneous injection of drugs not prescribed by a physician for medical purposes since 1977? | No | |
A person having engaged in sex in exchange for money or drugs at any time since 1977? | No | |
A person who has had sex with another person described in any of the above in the preceding 12 months? | No |
Have you: | ||
Question | Response | |
Have you been exposed to known or suspected HIV-infected blood through percutaneous inoculation or through contact with an open wound, non-intact skin, or mucous membrane within the preceding 12 months? | No |
Donor Genetic History | ||
Question | Response | |
Were you born with any birth defects? If yes, explain: | No | |
Are there any known genetic conditions or birth defects in your family? | No | |
Have you been tested for Cystic Fibrosis? If yes, the result: | Yes - During the donor screening process - non-carrier | |
Have you been tested for Alpha-1 Antitrypsin Disorder? If yes, the result: | No |
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 - N/A | |
Gaucher: If yes, result(s): | N/A - N/A | |
Canavan: If yes, result(s): | N/A - N/A |
Ancestry | ||
Question | Response | |
Are you of African ancestry? | No | |
If yes, have you been tested as a carrier of sickle cell anemia? | N/A - N/A | |
If yes, result: | This question was added after the donor's interview. | |
Are you of Mediterranean, Greek or Italian ancestry? | No | |
If yes, have you been tested as a carrier of thalassemia? | Yes - 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. |
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Heart attack | No None |
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Congenital heart disease | No None |
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Hemophilia/bleeding problem | No None |
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Severe bleeding tendency | No None |
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Cystic Fibrosis | No None |
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Alpha-1 Antitrypsin Disorder | No None |
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Pyloric stenosis | No None |
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Inflammatory bowel disease | No None |
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Diabetes mellitus requiring insulin therapy. | No None |
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Diabetes mellitus not requiring insulin therapy. | No None |
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PKU or inherited metabolism disorder | No None |
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Progressive kidney disease | No None |
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Polycystic kidney disease | No None |
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Miscarriages or stillborn | No None |
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Herpes simplex virus, genital | No None |
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Migraines | No None |
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Mental retardation | No None |
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Senility or mental deterioration before age 60 | No None |
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Epilepsy/seizures | No None |
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Neural tube defects - open spine or hypocephalus/water on the brain | No None |
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Huntington's disease | No None |
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Tuberous sclerosis | No None |
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Neurofibromatosis | No None |
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Parkinson's disease | No None |
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Down's syndrome/Mongolism | No None |
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Schizophrenia | No None |
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Manic depressive psychosis | No None |
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Muscular dystrophy | No None |
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Loss of muscle coordination | No None |
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Rheumatoid arthritis | No None |
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Reiter's disease | No None |
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Club foot | No None |
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Deafness before age of 60 | No None |
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Cataracts before age of 60 | No None |
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Blindness in both eyes before age of 60 | No None |
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Glaucoma | No None |
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Psoriasis | No None |
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Albinism | No None |
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More than 5 purple or coffee-colored spots on the skin (size of a quarter or larger) | No None |
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Drug abuse, misuse, or addiction | No None |
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Cleft palate or cleft lip | No None |
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Serious birth defects | No None |
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Inguinal hernia | No None |
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Premature degeneration of any organ system | No None |
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The same cancer in more than one family member | No None |
Donor Medical History | ||
Question | Response | |
List any operations: Year & reason: | None | |
Hospitalization other than surgery: Year & type of illness: | None | |
Have you ever had any broken bones? If yes, please describe: | No | |
Have you ever had any serious illnesses? If yes, please describe: | 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 - N/A | |
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: | N/A | |
List all current medication or treatments (include vitamins, aspirin, antacids, laxatives, herbal, sports supplements, etc.) Include drug, frequency and duration taken, and reason: | Multivitamin for general health | |
Do you wear glasses or contact lenses? Are you near or far-sighted? | No | |
Usual weight? | 172 | |
Recent loss or gain? # of lbs and reason: | No | |
Allergies (medicines, food, pollens)? If yes, please list substance and reaction caused: | No | |
Have you ever had occupational exposure to radiation or chemicals? If yes, please describe: | No | |
Have you had a fever with headache in the last seven days? If yes, when and why? | This question was added after the donor's interview. | |
Have you ever been refused as a blood donor? If yes, when and why? | No | |
Have you been tested for HIV (AIDS)? If yes, when: | Yes - Ongoing donor screening process | |
Sexual orientation: | Heterosexual | |
Number of current sexual partners: | 0 - No current sexual partners | |
Has any sexual partner ever been positive for HIV (AIDS)? If yes, describe: | No | |
Has any sexual partner had an episode of trichmoniasis? 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 had a blood transfusion in the last 12 months? If yes, what was the date of the transfusion? | 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 |
Please indicate whether you currently have, have had in the past, or have ever been treated for: | ||
Question | Response | |
Hydrocele | No | |
Syphilis | No | |
Blood transfusion | No | |
Prolonged fever | No | |
Herpes | No | |
Fever above 101 F (in the past 3 months) | No | |
Hepatitis B, C, other | No | |
Orchitis | No | |
Genital Warts/Papillomavirus | No | |
Epididymitis | No | |
Liver disease | No | |
Prostatitis | No | |
Renal disease | No | |
Mumps w/testes involved | No | |
Diabetes | No | |
Urethritis | No | |
Psychiatric disorders | No | |
Varicocele | No | |
Undescended testicle | No | |
AIDS | No | |
Tuberculosis | No | |
Alzheimer's disease | No | |
Multiple sclerosis | No | |
Creutzfeldt-Jacob disease (CJD or vCJD) | No | |
Note any comments regarding above items: | N/A |
Indicate conditions occurring now or in the past: | ||
Question | Response | |
rashes, color change | Yes - Rash due to poison ivy | |
frequent urinating | No | |
itching | No | |
waking to urinate # of times / night: | No | |
warts, moles | No | |
cancer | No | |
eczema, lumps, hives | No | |
sores or discharge | No | |
very dry skin | No | |
bleeding or bruising | No | |
excessive sweating | No | |
trouble swallowing | No | |
minor injury | No | |
poor appetite | No | |
anemia | No | |
gas, cramps, pains | No | |
lymph node or gland swelling | No | |
heartburn, indigestion | No | |
ear trouble, infection | No | |
nausea, vomiting, constipation, diarrhea | No | |
blood in stool or black stool | No | |
hearing loss, ringing in ear | No | |
yellow jaudice, hepatitis B or C | No | |
eye problems | No | |
hemorrhoids | No | |
nosebleeds | No | |
hernia | No | |
sore throats | No | |
gall bladder problems | No | |
stuffy nose, sinus trouble, hay fever | No | |
pains in joints, arthritis | No | |
high blood pressure | No | |
swollen joints | No | |
hoarseness | No | |
back pain, neck pain | No | |
dental or gum problems | No | |
head injury, concussion | No | |
enlarged or painful breasts | No | |
headaches | No | |
breast lumps | No | |
dizziness, fainting | No | |
discharge from nipples | No | |
convulsions, seizures, fits | No | |
shortness of breath | No | |
shaking, tremor | No | |
cough, chest colds | Yes - Occasional cold | |
weakness, paralysis | No | |
bringing up sputum with blood | No | |
numbness, tingling | No | |
wheezing, asthma | No | |
difficulty walking, coordination | No | |
chest pain, pleurisy | No | |
poor circulation, varicose veins | No | |
TB or exposure to TB | No | |
depression, anxiety | No | |
fevers, sweats, chills | No | |
poor sleeping | No | |
pneumonia | No | |
nervousness, tension | No | |
fast or irregular heartbeat | No | |
trouble thinking, remembering | No | |
chest pain, tightness, pressure | No | |
crying, upset, worrying | No | |
trouble breathing when lying down | No | |
sexual problems | No | |
waking short of breath | No | |
goiter, thyroid problems | No | |
swelling of feet or ankles | No | |
blood clots | No | |
previous heart trouble | No | |
murmurs or rheumatic fever | No | |
CMV IgG Antibody | Negative | |
CMV IgM Antibody | Negative | |
Any other comments | N/A |
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 | 63 | | Health Problem |
Living / Dead | Living | |
|
Your FatherQuestion | Response | Comment/Age Affected | Current age or age at death | 71 | | Health Problem |
Living / Dead | Living | |
|
Brother(s) |
Your Brother 1Question | Response | Comment/Age Affected | Current age or age at death | 41 | | Health Problem |
Living / Dead | Living | |
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Your Mother's FatherQuestion | Response | Comment/Age Affected | Current age or age at death | 78 | | Health Problem |
Living / Dead | Dead | |
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Your Mother's MotherQuestion | Response | Comment/Age Affected | Current age or age at death | 85 | | Health Problem |
Living / Dead | Living | |
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Your Mother's Brothers 1Question | Response | Comment/Age Affected | Current age or age at death | 38 | | Health Problem |
Living / Dead | Living | |
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Your Father's FatherQuestion | Response | Comment/Age Affected | Current age or age at death | 68 | | Health Problem |
Living / Dead | Dead | |
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Your Father's MotherQuestion | Response | Comment/Age Affected | Current age or age at death | 58 | | Health Problem |
Living / Dead | Dead | |
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