| 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. |
||
| Heart attack | No None |
|
| Congenital heart disease | No None |
|
| Hemophilia/bleeding problem | No None |
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| Severe bleeding tendency | No None |
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| Cystic Fibrosis | No None |
|
| Alpha-1 Antitrypsin Disorder | No None |
|
| Pyloric stenosis | No None |
|
| Inflammatory bowel disease | No None |
|
| Diabetes mellitus requiring insulin therapy. | No None |
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| Diabetes mellitus not requiring insulin therapy. | No None |
|
| 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 |
|
| Miscarriages or stillborn | No None |
|
| Herpes simplex virus, genital | No None |
|
| Migraines | No None |
|
| Mental retardation | No None |
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| Senility or mental deterioration before age 60 | No None |
|
| Epilepsy/seizures | No None |
|
| 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 Mother| Question | Response | Comment/Age Affected | Current age or age at death | 63 | | Health Problem |
Living / Dead | Living | |
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Your Father| Question | Response | Comment/Age Affected | Current age or age at death | 71 | | Health Problem |
Living / Dead | Living | |
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| Brother(s) |
Your Brother 1| Question | Response | Comment/Age Affected | Current age or age at death | 41 | | Health Problem |
Living / Dead | Living | |
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Your Mother's Father| Question | Response | Comment/Age Affected | Current age or age at death | 78 | | Health Problem |
Living / Dead | Dead | |
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Your Mother's Mother| Question | Response | Comment/Age Affected | Current age or age at death | 85 | | Health Problem |
Living / Dead | Living | |
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Your Mother's Brothers 1| Question | Response | Comment/Age Affected | Current age or age at death | 38 | | Health Problem |
Living / Dead | Living | |
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Your Father's Father| Question | Response | Comment/Age Affected | Current age or age at death | 68 | | Health Problem |
Living / Dead | Dead | |
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Your Father's Mother| Question | Response | Comment/Age Affected | Current age or age at death | 58 | | Health Problem |
Living / Dead | Dead | |
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