Donor 0351 - Medical Profile

Personal Behavior History

Question	Response
Current alcohol use: If yes, oz./week and type of alcohol:	Rarely - 0.5 oz./week
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?	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 - (possibly lactose intolerant)
Are you a vegetarian?	N/A
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?	N/A
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 for at least 86 mutations
Karyotype? If yes, the result:	Yes - Normal karyotype
Spinal Muscular Atrophy (SMA)? If yes, the result:	Unknown - Donor was not tested
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 Type C: If yes, result(s):	N/A
Niemann-Pick Type A: 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 Disease 1B: 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
Lipoamide Dehydrogenase Deficiency: 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?	N/A - N/A
If yes, result:	Non Carrier
Are you of Mediterranean, Greek or Italian ancestry?	No
If yes, have you been tested as a carrier of beta thalassemia?	Yes - Standard donor screening
If yes, result:	Non Carrier

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	No
Congenital heart disease	No
Hemophilia/bleeding problem	No
Emphysema	N/A
Cystic Fibrosis	No
Alpha-1 Antitrypsin Deficiency
Pyloric stenosis	No
Colon cancer	N/A
Inflammatory bowel disease	No
Irritable Bowel Syndrome	N/A
Diabetes mellitus requiring insulin therapy	No
Diabetes mellitus not requiring insulin therapy	No
PKU or inherited metabolism disorder	No
Progressive kidney disease	No
Polycystic kidney disease	No
Miscarriages or stillborn	No
Herpes simplex virus, genital	No
Migraines	No
Mental retardation	No
Senility or mental deterioration before age 60	No
Epilepsy/seizures	No
Neural tube defects - open spine or hydrocephalus/water on the brain	No
Huntington's disease	No
Tuberous sclerosis	No
Neurofibromatosis	No
Parkinson's disease	No
Down Syndrome	No
Autism	N/A
Autism Spectrum Disorder	N/A
Pervasive Developmental Delay (PDD)	N/A
Asperger's Syndrome	N/A
Schizophrenia	No
Bipolar (manic depressive psychosis)	No
Attention Deficit Disorder (ADD)	N/A
Attention Deficit Hyperactivity Disorder (ADHD)	N/A
Muscular Dystrophy	No
Loss of muscle coordination	No
Rheumatoid Arthritis	No
Reiter's Disease	No
Club foot	No
Deafness before age of 60	No
Cataracts before age of 60	No
Blindness in both eyes before age of 60	No
Glaucoma	No
Macular Degeneration	N/A
Acne	N/A
Psoriasis	No
Albinism	No
More than 5 purple or coffee-colored spots on the skin-1.5 cm (1/2 inch) or larger	No
Drug abuse, misuse, or addiction	No
Cleft palate or cleft lip	No
Serious birth defects	No
Inguinal hernia	No
Premature degeneration of any organ system	No
The same cancer in more than one family member	No

Donor Medical History

Question	Response
List any operations: Age & reason:	8 years ago, oral surgery to remove wisdom teeth
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:	N/A
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:	Tylenol, once every 3-4 months for headache
List all current medication or treatments (include vitamins, aspirin, antacids, laxatives, herbal, sports supplements, etc.) Include drug, frequency and duration taken, and reason:	Vitamins, every day as a dietary supplement
Do you wear glasses or contact lenses? Are you near or far-sighted?	Yes
Usual weight?	159
Recent weight loss or gain? # of lbs and reason:	No
Allergies (medicines, food, pollens)? If yes, please list substance and reaction caused:	Yes - Pollen, seasonal
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?	No

Family Medical History
See list of questions asked here

Your Mother

Question	Response	Comment/Age Affected
Current age or age at death	59
Health Problem	High blood pressure	55
Living / Dead	Living

Your Father

Question	Response	Comment/Age Affected
Current age or age at death	61
Health Problem	Healthy
Living / Dead	Living

Brothers

Your Brother 1

Question	Response	Comment/Age Affected
Current age or age at death	24
Health Problem	Healthy
Living / Dead	Living

Sisters

Your Sister 1

Question	Response	Comment/Age Affected
Current age or age at death	28
Health Problem	Healthy
Living / Dead	Living

Your Mother's Father

Question	Response	Comment/Age Affected
Current age or age at death	42
Health Problem	Cause of death: Execution during Communist revolution	42
Living / Dead	Dead

Your Mother's Mother

Question	Response	Comment/Age Affected
Current age or age at death	76
Health Problem	Unknown, died in rural China	76
Living / Dead	Dead

Your Mother's Brothers 1

Question	Response	Comment/Age Affected
Current age or age at death	62
Health Problem	Healthy
Living / Dead	Living

Your Mother's Brothers 2

Question	Response	Comment/Age Affected
Current age or age at death	58
Health Problem	Healthy
Living / Dead	Living

Your Father's Father

Question	Response	Comment/Age Affected
Current age or age at death	79
Health Problem	Unknown, died in rural China	79
Living / Dead	Dead

Your Father's Mother

Question	Response	Comment/Age Affected
Current age or age at death	89
Health Problem	Unknown, died in rural China	89
Living / Dead	Dead

Your Father's Sisters 1

Question	Response	Comment/Age Affected
Current age or age at death	55
Health Problem	Healthy
Living / Dead	Living

Your Father's Sisters 2

Question	Response	Comment/Age Affected
Current age or age at death	47
Health Problem	Healthy
Living / Dead	Living

Your Father's Sisters 3

Question	Response	Comment/Age Affected
Current age or age at death	42
Health Problem	Healthy
Living / Dead	Living

Your Father's Brothers 1

Question	Response	Comment/Age Affected
Current age or age at death	58
Health Problem	Healthy
Living / Dead	Living

Your Father's Brothers 2

Question	Response	Comment/Age Affected
Current age or age at death	54
Health Problem	Healthy
Living / Dead	Living

Your Father's Brothers 3

Question	Response	Comment/Age Affected
Current age or age at death	38
Health Problem	Healthy
Living / Dead	Living

Your Father's Brothers 4

Question	Response	Comment/Age Affected
Current age or age at death	35
Health Problem	Healthy
Living / Dead	Living

Donor Number: 0351

Personal Behavior History

Sexual History

Donor Genetic History

Donor Medical History

Family Medical HistorySee list of questions asked here

Family Medical History
See list of questions asked here