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Personal Behavior History

Question Response
Current alcohol use:
If yes, oz./week and type of alcohol:
Regularly - 12 oz. beer or liquor/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 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
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 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
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:
None
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:
1 - Cold
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:None
Do you wear glasses or contact lenses?
Are you near or far-sighted?
No - (Near-sighted before laser surgery)
Usual weight?234
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?
No
Have you ever had your ear(s) or body pierced?
If yes, where and what year?
Yes - Ears, in 1997

Family Medical History
See list of questions asked here

Question Response
Current age or age at death 60
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Disease
Age Diagnosed
Treatment For Condition
High blood pressure
55
Medication
Question Response
Current age or age at death 63
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Question Response
Current age or age at death 29
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Question Response
Current age or age at death 85
Living / DeadDead
Cause of death and any treatment prior to deathHeart failure
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Heart failure
85
Unknown
Question Response
Current age or age at death 92
Living / DeadDead
Cause of death and any treatment prior to deathHeart failure
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Heart failure
92
Unknown
Question Response
Current age or age at death 64
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Question Response
Current age or age at death 67
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Question Response
Current age or age at death 56
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Question Response
Current age or age at death 84
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Question Response
Current age or age at death 80
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Question Response
Current age or age at death 51
Living / DeadDead
Cause of death and any treatment prior to deathPneumonia
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Pneumonia
51
Unknown
Question Response
Current age or age at death 10
Living / DeadDead
Cause of death and any treatment prior to deathKidney failure
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Kidney failure
10
None