| Cryogenic Laboratories, Inc. |
| Donor 4535 Medical Profile |
| Questions |
| Personal Behavior History |
| Donor Genetic History |
| Donor Medical History |
| Family Medical History |
| Personal Behavior History | ||
| Question | Response | |
| Current alcohol use: If yes, oz./week and type of alcohol: | Occasionally - 12 oz. beer/week | |
| Do you or any of your relatives have a history of alcoholism or alcohol abuse? 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? | N/A | |
| How many packs per day? | N/A | |
| 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 | |
| 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 | |
| A person having intravenous, intramuscular, or subcutaneous injection of drugs not prescribed by a licensed physician for medical purposes? | No | |
| Have you: | ||
| Question | Response | |
| 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 99 mutations tested | |
| Have you had any additional genetic testing? If yes, complete the following: | Yes - Karyotype and SMA | |
| 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: | Unknown - Donor was not tested | |
| 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: If yes, result(s): | N/A | |
| Niemann-Pick: 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 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 | |
| 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 thalassemia? | Yes - Standard donor screening | |
| If yes, result: | Non Carrier | |
| Have you or any member of your family had 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 |
|
| Severe bleeding tendency | None |
|
| Cystic Fibrosis | None |
|
| Alpha-1 Antitrypsin Disorder | None |
|
| Pyloric stenosis | None |
|
| Colon cancer | None |
|
| Inflammatory bowel disease | None |
|
| Irritable Bowel Syndrome | None |
|
| Diabetes mellitus requiring insulin therapy. | None |
|
| Diabetes mellitus not requiring insulin therapy. | None |
|
| PKU or inherited metabolism disorder | None |
|
| Progressive kidney disease | None |
|
| Polycystic kidney disease | None |
|
| Miscarriages or stillborn | None |
|
| Herpes simplex virus, genital | None |
|
| Migraines | None |
|
| 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's syndrome/Mongolism | None |
|
| Autism | None |
|
| Autism Spectrum Disorder | None |
|
| PDD (pervasive developmental delay) | None |
|
| Asperger's Syndrome | None |
|
| Schizophrenia | None |
|
| Manic depressive psychosis | None |
|
| Attention Deficit Disorder (ADD) | None |
|
| Attention Deficit Hyperactivity Disorder (ADHD) | None |
|
| 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 | None |
|
| Macular Degeneration | None |
|
| Acne | Self - ages 16-18 (treated with over-the-counter medication) |
|
| 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: | Tonsillectomy at age 8 to help reduce drooling while sleeping; Wisdom teeth extraction surgery at age 17 | |
| Hospitalization other than surgery: Age & type of illness: | None | |
| 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: | Whey Protein, Multivitamin, taken daily for general health; Advil, used occasionally for headache relief; Benadryl, taken as needed for seasonal allergies | |
| List all current medication or treatments (include vitamins, aspirin, antacids, laxatives, herbal, sports supplements, etc.) Include drug, frequency and duration taken, and reason: | Whey Protein, Multivitamin, taken daily for general health | |
| Do you wear glasses or contact lenses? Are you near or far-sighted? | No | |
| Usual weight? | 146 | |
| Recent loss or gain? # of lbs and reason: | No | |
| Allergies (medicines, food, pollens)? If yes, please list substance and reaction caused: | Yes - Seasonal: Sneezing, runny nose | |
| Have you been exposed to, or been at risk of exposure to: radiation, chemicals, or toxic amounts of lead, mercury, or gold? If yes, please describe: | No | |
| Have you been permanently excluded or deferred from donating blood or plasma? If yes, when and why? | No | |
| Have you been tested for HIV (AIDS)? If yes, when: | Yes - Negative, ongoing donor screening | |
| Sexual orientation: | Heterosexual | |
| Number of current sexual partners: | 0 | |
| Have you had a partner who has had cultures of Trichomonas? If yes, describe: | 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 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 | |
| Family Medical History |
Your Mother| Question | Response | Comment/Age Affected | Current age or age at death | 45 | | Health Problem |
Living / Dead | Living | |
| ||||||
Your Father| Question | Response | Comment/Age Affected | Current age or age at death | 45 | | Health Problem |
Living / Dead | Living | |
| ||||||
| Brother(s) |
Your Brother 1| Question | Response | Comment/Age Affected | Current age or age at death | 24 | | Health Problem |
Living / Dead | Living | |
| ||||||
| Sister(s) |
Your Sister 1| Question | Response | Comment/Age Affected | Current age or age at death | 21 | | Health Problem |
Living / Dead | Living | | | ||||||
Your Sister 2| Question | Response | Comment/Age Affected | Current age or age at death | 20 | | Health Problem |
Living / Dead | Living | |
| ||||||
Your Mother's Mother| Question | Response | Comment/Age Affected | Current age or age at death | 77 | | Health Problem |
Living / Dead | Living | |
| ||||||
Your Mother's Sisters 1| Question | Response | Comment/Age Affected | Current age or age at death | 56 | | Health Problem |
Living / Dead | Living | |
| ||||||
Your Mother's Brothers 1| Question | Response | Comment/Age Affected | Current age or age at death | 44 | | Health Problem |
Living / Dead | Living | | | ||||||
Your Mother's Brothers 2| Question | Response | Comment/Age Affected | Current age or age at death | 35 | | Health Problem |
Living / Dead | Living | | | ||||||
Your Mother's Brothers 3| Question | Response | Comment/Age Affected | Current age or age at death | 33 | | Health Problem |
Living / Dead | Dead | |
| ||||||||
Your Father's Father| Question | Response | Comment/Age Affected | Current age or age at death | 70 | | Health Problem |
Living / Dead | Living | |
| ||||||
Your Father's Mother| Question | Response | Comment/Age Affected | Current age or age at death | 68 | | Health Problem |
Living / Dead | Living | |
| ||||||
Your Father's Sisters 1| Question | Response | Comment/Age Affected | Current age or age at death | 49 | | Health Problem |
Living / Dead | Living | | | ||||||
Your Father's Sisters 2| Question | Response | Comment/Age Affected | Current age or age at death | 47 | | Health Problem |
Living / Dead | Living | |
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