This donor is a healthy carrier for a genetic disease.
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:
Occasionally - 1oz. vodka/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

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
Question Response
Are you of Jewish ancestry?
If yes, please note: Ashkenazi, Sephardi, or Other
No
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
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 - at age 20
Hospitalization other than surgery:
Age & type of illness:
No
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 B Complex, Vitamin D3, Daily Multi-vitamin, all taken for general health
Do you wear glasses or contact lenses?
Are you near or far-sighted?
Yes - Near sighted, age 12
Usual weight?191
Recent weight loss or gain?
# of lbs and reason:
No
Allergies (medicines, food, pollens)?
If yes, please list substance and reaction caused:
Yes - Minor seasonal allergies, age 15 (treated with over the counter medication, causes stuffy nose); Coconut, age 7 (causes hives)
Have you been tested for HIV (AIDS)?
If yes, when:
Yes - Negative, ongoing donor screening
How many sexual partners do you currently have?0
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

Question Response
Current age or age at death 60
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Problemas de Saúde
Disease
Age Diagnosed
Treatment For Condition
Hay fever/Seasonal Allergies/Allergic Rhinitis
15
Over the counter medication during spring/summer
Question Response
Current age or age at death 55
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Problemas de Saúde
Saudável
Question Response
Current age or age at death 23
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Problemas de Saúde
Disease
Age Diagnosed
Treatment For Condition
Hay fever/Seasonal Allergies/Allergic Rhinitis
10
Over the counter medication for spring/summer
Question Response
Current age or age at death 82
Living / DeadDead
Cause of death and any treatment prior to deathHeart failure
Problemas de Saúde
Disease
Age Diagnosed
Treatment For Condition
Heart failure
82
None
Question Response
Current age or age at death 77
Living / DeadDead
Cause of death and any treatment prior to deathMesothelioma cancer caused by asbestos exposure
Problemas de Saúde
Disease
Age Diagnosed
Treatment For Condition
Lung cancer
73
No treatment for mesothelioma caused by asbestos exposure
Question Response
Current age or age at death 57
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Problemas de Saúde
Saudável
Question Response
Current age or age at death 47
Living / DeadDead
Cause of death and any treatment prior to deathAccidental death
Problemas de Saúde
Saudável
Question Response
Current age or age at death 87
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Problemas de Saúde
Saudável
Question Response
Current age or age at death 85
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Problemas de Saúde
Saudável
Question Response
Current age or age at death 65
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Problemas de Saúde
Saudável
Question Response
Current age or age at death 63
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Problemas de Saúde
Saudável
Question Response
Current age or age at death 59
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Problemas de Saúde
Saudável