Personal Behavior History
Donor Sexual History
Donor Genetic History
Donor Medical History
Family Medical HistoryThis donor is a healthy carrier for a genetic disease.
Please see his Genetic Testing Summary and Acknowledgment of Genetic Risk for details
Please see his Genetic Testing Summary and Acknowledgment of Genetic Risk for details
Personal Behavior History
| Question | Response |
| Current alcohol use: If yes, oz./week and type of alcohol: | Regularly - 60oz. beer/week |
| 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 |
| For how many years? | N/A |
| 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 |
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 by gene sequencing |
| Karyotype? If yes, the result: | Yes - Normal karotype |
| Spinal Muscular Atrophy (SMA)? If yes, the result: | Non Carrier - by gene sequencing |
| Tay Sachs? If yes, the result: | Non Carrier - by gene sequencing |
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): | Yes - Non-carrier by gene sequencing |
| Gaucher: If yes, result(s): | Yes - Non-carrier by gene sequencing |
| Canavan: If yes, result(s): | Yes - Non-carrier by gene sequencing |
| Fanconi Anemia Type C: If yes, result(s): | Yes - Non-carrier by gene sequencing |
| Niemann-Pick Type A: If yes, result(s): | Yes - Non-carrier by gene sequencing |
| Bloom Syndrome: If yes, result(s): | Yes - Non-carrier by gene sequencing |
| Familial Dysautonomia: If yes, result(s): | Yes - Non-carrier by gene sequencing |
| Mucolipidosis IV: If yes, result(s): | Yes - Non-carrier by gene sequencing |
| Maple Syrup Urine Disease 1B: If yes, result(s): | Yes - Non-carrier by gene sequencing |
| Usher Syndrome III & 1F: If yes, result(s): | Yes - Non-carrier by gene sequencing |
| Glycogen Storage Disease 1A: If yes, result(s): | Yes - Non-carrier by gene sequencing |
| ABCC8-Related Hyperinsulinism: If yes, result(s): | Yes - Non-carrier by gene sequencing |
| Lipoamide Dehydrogenase Deficiency: If yes, result(s): | Yes - Non-carrier by gene sequencing |
Ancestry
| Question | Response |
| Are you of African ancestry? | No |
| If yes, have you been tested as a carrier of sickle cell anemia? | Yes |
| If yes, result: | Non Carrier - by gene sequencing |
| Are you of Mediterranean, Greek or Italian ancestry? | No |
| If yes, have you been tested as a carrier of beta thalassemia? | Yes |
| If yes, result: | Non Carrier - by gene sequencing |
Donor Medical History
| Question | Response |
| List any operations: Age & reason: | Wisdom teeth removal (age 17) |
| Hospitalization other than surgery: Age & type of illness: | N/A |
| Have you ever had any broken bones? If yes, please give age and description: | No |
| 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: | None |
| List all current medication or treatments (include vitamins, aspirin, antacids, laxatives, herbal, sports supplements, etc.) Include drug, frequency and duration taken, and reason: | Vitamin occasionally, for general health |
| Do you wear glasses or contact lenses? Are you near or far-sighted? | No |
| Usual weight? | 163 |
| 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 |
| How many sexual partners do you currently have? | 1 |
| Have you ever had a tattoo? If yes, what year did you get the tattoo? | Yes - 2011 |
| 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 |
| Current age or age at death | 63 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Problemas de Saúde
Saudável
Your Father
| Question | Response |
| Current age or age at death | 63 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Problemas de Saúde
Saudável
Brothers
Your Brother 1
| Question | Response |
| Current age or age at death | 35 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Problemas de Saúde
Saudável
Sisters
Your Sister 1
| Question | Response |
| Current age or age at death | 29 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Problemas de Saúde
Saudável
Your Sister 2
| Question | Response |
| Current age or age at death | 25 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Problemas de Saúde
Disease
Age Diagnosed
Treatment For Condition
Orthostatic Hypotension
25
No treatment currently
Your Mother's Father
| Question | Response |
| Current age or age at death | 90 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Problemas de Saúde
Disease
Age Diagnosed
Treatment For Condition
COPD
85
None
Heart failure
86
Medication controlled
Your Mother's Mother
| Question | Response |
| Current age or age at death | 89 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Problemas de Saúde
Disease
Age Diagnosed
Treatment For Condition
Dementia
83
Medication controlled
Your Mother's Sisters 1
| Question | Response |
| Current age or age at death | 0.1 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | N/A |
Problemas de Saúde
Disease
Age Diagnosed
Treatment For Condition
Newborn death, cause unknown.
None
Your Mother's Sisters 2
| Question | Response |
| Current age or age at death | 64 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Problemas de Saúde
Saudável
Your Mother's Brothers 1
| Question | Response |
| Current age or age at death | 58 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Problemas de Saúde
Saudável
Your Father's Father
| Question | Response |
| Current age or age at death | 86 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Cancer |
Problemas de Saúde
Disease
Age Diagnosed
Treatment For Condition
Melanoma Cancer
86
No treatment
Your Father's Mother
| Question | Response |
| Current age or age at death | 87 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Problemas de Saúde
Disease
Age Diagnosed
Treatment For Condition
High blood pressure
85
Medication controlled
High cholesterol
85
Medication controlled
Your Father's Sisters 1
| Question | Response |
| Current age or age at death | 61 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Problemas de Saúde
Saudável
Your Father's Brothers 1
| Question | Response |
| Current age or age at death | 58 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Problemas de Saúde
Disease
Age Diagnosed
Treatment For Condition
Asthma
40
Inhaler controlled
Diverticulitis
57
Diet controlled
Your Father's Brothers 2
| Question | Response |
| Current age or age at death | 60 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Problemas de Saúde
Saudável