Personal Behavior History
Donor Sexual History
Donor Genetic History
Donor Medical History
Family Medical HistoryA medical update has been received. Check the Summary Profile Update Section
Personal Behavior History
| Question | Response |
| Current alcohol use: If yes, oz./week and type of alcohol: | Occasionally - 3-4 drinks/month; mainly beer, occasionally wine |
| Have you or any of your family members been diagnosed with alcoholism or drug addiction? 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? | Never |
| 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 |
| Are you a vegetarian? | No |
| Any dietary restrictions? If yes, explain: | No - But I choose to eat mostly organic foods |
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 |
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 karyotype |
| Spinal Muscular Atrophy (SMA)? If yes, the result: | Non Carrier - Standard donor screening |
| Tay Sachs? If yes, the result: | Non Carrier - by gene sequencing and enzyme analysis |
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 for mutations tested |
| 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 |
| BRCA1/BRCA2: If yes, result(s): | No |
| 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 |
Have you or any member of your family had, currently have or been diagnosed with 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 | Grandparent - Paternal grandfather, age 80 |
| Congenital heart disease | None |
| Hemophilia/bleeding problem | None |
| Emphysema | Grandparent - Maternal grandfather, age 74 |
| Cystic Fibrosis | None |
| Alpha-1 Antitrypsin Deficiency | 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 Syndrome | None |
| Autism | None |
| Autism Spectrum Disorder | None |
| Pervasive Developmental Delay (PDD) | None |
| Asperger's Syndrome | None |
| Schizophrenia | None |
| Bipolar (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 14-17, 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: | Septoplasty at ages 12, 13 (for broken nose), and 25 (to repair deviated septum and crooked nose); Adenoidectomy at age 13; Wisdom teeth extraction at age 17; Torn meniscus at age 26 |
| Hospitalization other than surgery: Age & type of illness: | N/A |
| Have you ever had any broken bones? If yes, please give age and description: | Yes - Broken nose at ages 12 (sports) and 13 (household accident) |
| 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: | 1 - Stomach flu |
| 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: | Multivitamin, Whey protein powder, Casein protein powder, Glutamine powder, HEED electrolyte powder, all taken daily; Caffeine pills taken before races (12-13 times per year) |
| List all current medication or treatments (include vitamins, aspirin, antacids, laxatives, herbal, sports supplements, etc.) Include drug, frequency and duration taken, and reason: | Multivitamin, taken daily |
| Do you wear glasses or contact lenses? Are you near or far-sighted? | No |
| Usual weight? | 164 |
| 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 |
| Sexual orientation: | Heterosexual |
| How many sexual partners do you currently have? | 1 |
| 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? | Yes - Ears, ages 18 and 20 |
Family Medical HistorySee list of questions asked here
Your Mother
| Question | Response | Comment/Age Affected |
| Current age or age at death | 60 | |
| Health Problem | High blood pressure, controlled with medication and exercise | 55 |
| High cholesterol, controlled with medication and exercise | 55 | |
| Living / Dead | Living |
Your Father
| Question | Response | Comment/Age Affected |
| Current age or age at death | 59 | |
| Health Problem | Healthy | |
| Living / Dead | Living |
Sisters
Your Sister 1
| Question | Response | Comment/Age Affected |
| Current age or age at death | 30 | |
| Health Problem | Asthma, for about one year, used an inhaler when needed | 9 |
| Kidney stone, passed normally | 13 | |
| Living / Dead | Living |
Your Sister 2
| Question | Response | Comment/Age Affected |
| Current age or age at death | 26 | |
| Health Problem | Healthy | |
| Living / Dead | Living |
Your Mother's Father
| Question | Response | Comment/Age Affected |
| Current age or age at death | 76 | |
| Health Problem | Emphysema, managed with oxygen (heavy smoker) | 74 |
| Alzheimer's, managed with medication | 75 | |
| Lung cancer, treated with chemotherapy | 75 | |
| Cause of death: Lung cancer | 76 | |
| Living / Dead | Dead |
Your Mother's Mother
| Question | Response | Comment/Age Affected |
| Current age or age at death | 81 | |
| Health Problem | Bronchitis, hospitalized, treated with medication | 78 |
| Chronic obstructive pulmonary disease (COPD), treated with medication (heavy smoker) | 80 | |
| Cause of death: COPD | 81 | |
| Living / Dead | Dead |
Your Mother's Brothers 1
| Question | Response | Comment/Age Affected |
| Current age or age at death | 67 | |
| Health Problem | Healthy | |
| Living / Dead | Living |
Your Father's Father
| Question | Response | Comment/Age Affected |
| Current age or age at death | 81 | |
| Health Problem | Alzheimer's, managed with medication | 79 |
| Heart attack, no treatment | 80 | |
| Stroke, no treatment | 81 | |
| Cause of death: Stroke | 81 | |
| Living / Dead | Dead |
Your Father's Mother
| Question | Response | Comment/Age Affected |
| Current age or age at death | 83 | |
| Health Problem | Osteoporosis, treated with calcium supplements | 75 |
| Stomach cancer, treated with chemotherapy | 81 | |
| Cause of death: Stomach cancer | 83 | |
| Living / Dead | Dead |
Your Father's Sisters 1
| Question | Response | Comment/Age Affected |
| Current age or age at death | 64 | |
| Health Problem | Healthy | |
| Living / Dead | Living |