Fairfax Cryobank

Donor 2369 Medical Profile

Questions

*Personal Behavior History*
Question	Response
Alcohol use: If yes, oz./week and type of alchohol:	Occasionally - 48 oz beer/week
Any relatives with alcoholism? 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?	0
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
Another man anal or oral, even once, since 1977?	No
A person having non-medical intravenous, intramuscular, or subcutaneous injection of drugs not prescribed by a physician for medical purposes since 1977?	No
A person having engaged in sex in exchange for money or drugs at any time since 1977?	No
A person who has had sex with another person described in any of the above in the preceding 12 months?	No

*Have you:*
Question	Response
Have you been exposed to known or suspected HIV-infected blood through percutaneous inoculation or through contact with an open wound, non-intact skin, or mucous membrane within the preceding 12 months?	No

*Donor Genetic History*
Question	Response
Were you born with any birth defects? If yes, explain:	No
Are there any known genetic conditions or birth defects in your family?	No
Have you been tested for Cystic Fibrosis? If yes, the result:	Yes - Non Carrier for at least 86 mutations
Have you been tested for Alpha-1 Antitrypsin Disorder? If yes, the result:	Yes - Non carrier

*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

*Ancestry*
Question	Response
Are you of African ancestry?	No
If yes, have you been tested as a carrier of sickle cell anemia?	N/A
If yes, result:	N/A
Are you of Mediterranean, Greek or Italian ancestry?	Yes
If yes, have you been tested as a carrier of thalassemia?	Yes
If yes, result:	Non Carrier

Have you, any member of your family, or any relative had or currently have any of the following conditions? Explain any conditions, indicating which side of the family (maternal/paternal), the age of the family member at the onset of the condition/ problem, and any other pertinent information.
Heart attack	Grandparent - Paternal grandfather at age 65 and maternal grandfather at age 81
Congenital heart disease	None
Hemophilia/bleeding problem	None
Severe bleeding tendency	None
Cystic Fibrosis	None
Alpha-1 Antitrypsin Disorder	None
Pyloric stenosis	None
Inflammatory bowel disease	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 hypocephalus/water on the brain	None
Huntington's disease	None
Tuberous sclerosis	None
Neurofibromatosis	None
Parkinson's disease	None
Down's syndrome/Mongolism	None
Schizophrenia	None
Manic depressive psychosis	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
Psoriasis	None
Albinism	None
More than 5 purple or coffee-colored spots on the skin (size of a quarter 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: Year & reason:	2000 Wisdom tooth removal
Hospitalization other than surgery: Year & type of illness:	N/A
Have you ever had any broken bones? If yes, please describe:	No
Have you ever had any serious illnesses? If yes, please describe:	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:	Mulivitamin every day
List all current medication or treatments (include vitamins, aspirin, antacids, laxatives, herbal, sports supplements, etc.) Include drug, frequency and duration taken, and reason:	Multivitamin every day
Do you wear glasses or contact lenses? Are you near or far-sighted?	Yes - Near-sighted
Usual weight?	140
Recent loss or gain? # of lbs and reason:	No
Allergies (medicines, food, pollens)? If yes, please list substance and reaction caused:	No
Have you ever had occupational exposure to radiation or chemicals? If yes, please describe:	No
Have you had a fever with headache in the last seven days? If yes, when and why?	No
Have you ever been refused as a blood donor? If yes, when and why?	No
Have you been tested for HIV (AIDS)? If yes, when:	Yes - 2005, negative
Sexual orientation:	Heterosexual
Number of current sexual partners:	1
Has any sexual partner ever been positive for HIV (AIDS)? If yes, describe:	No
Has any sexual partner had an episode of trichmoniasis? If yes, describe:	No
Have you ever been convicted of a felony? If yes, please explain:	No
Have you ever had a tattoo? If yes, what year did you get the tattoo?	Yes - 1996, 2002, 2003, 2004
Have you ever had your ear(s) or body pierced? If yes, where and what year?	Yes - 1996, bilateral earlobes
Have you had a blood transfusion in the last 12 months? If yes, what was the date of the transfusion?	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

*Please indicate whether you currently have, have had in the past, or have ever been treated for:*
Question	Response
Hydrocele	No
Syphilis	No
Blood transfusion	No
Prolonged fever	No
Herpes	No
Fever above 101 F (in the past 3 months)	No
Hepatitis B, C, other	No
Orchitis	No
Genital Warts/Papillomavirus	No
Epididymitis	No
Liver disease	No
Prostatitis	No
Renal disease	No
Mumps w/testes involved	No
Diabetes	No
Urethritis	No
Psychiatric disorders	No
Varicocele	No
Undescended testicle	No
AIDS	No
Tuberculosis	No
Alzheimer's disease	No
Multiple sclerosis	No
Creutzfeldt-Jacob disease (CJD or vCJD)	No
Note any comments regarding above items:	N/A

*Indicate conditions occurring now or in the past:*
Question	Response
rashes, color change	No
frequent urinating	No
itching	No
waking to urinate # of times / night:	No
warts, moles	No
cancer	No
eczema, lumps, hives	No
sores or discharge	No
very dry skin	No
bleeding or bruising	No
excessive sweating	No
trouble swallowing	No
minor injury	No
poor appetite	No
anemia	No
gas, cramps, pains	No
lymph node or gland swelling	No
heartburn, indigestion	No
ear trouble, infection	No
nausea, vomiting, constipation, diarrhea	No
blood in stool or black stool	No
hearing loss, ringing in ear	No
yellow jaudice, hepatitis B or C	No
eye problems	No
hemorrhoids	No
nosebleeds	No
hernia	No
sore throats	No
gall bladder problems	No
stuffy nose, sinus trouble, hay fever	No
pains in joints, arthritis	No
high blood pressure	No
swollen joints	No
hoarseness	No
back pain, neck pain	No
dental or gum problems	No
head injury, concussion	No
enlarged or painful breasts	No
headaches	No
breast lumps	No
dizziness, fainting	No
discharge from nipples	No
convulsions, seizures, fits	No
shortness of breath	No
shaking, tremor	No
cough, chest colds	No
weakness, paralysis	No
bringing up sputum with blood	No
numbness, tingling	No
wheezing, asthma	No
difficulty walking, coordination	No
chest pain, pleurisy	No
poor circulation, varicose veins	No
TB or exposure to TB	No
depression, anxiety	No
fevers, sweats, chills	No
poor sleeping	No
pneumonia	No
nervousness, tension	No
fast or irregular heartbeat	No
trouble thinking, remembering	No
chest pain, tightness, pressure	No
crying, upset, worrying	No
trouble breathing when lying down	No
sexual problems	No
waking short of breath	No
goiter, thyroid problems	No
swelling of feet or ankles	No
blood clots	No
previous heart trouble	No
murmurs or rheumatic fever	No
CMV IgG Antibody	Negative
CMV IgM Antibody	Negative
Any other comments	N/A

Family Medical History

Complete for each of the following relatives. List all specific health problems, operations, and/or causes of death (include stillborns, infant deaths and childhood deaths) for each individual.

Your Mother

Question

Response

Comment/Age Affected

Current age or age at death

Health Problem

Healthy

Living / Dead

Living

Your Father

Question

Response

Comment/Age Affected

Current age or age at death

Health Problem

Healthy

Living / Dead

Living

Brother(s)

Your Brother 1

Question

Response

Comment/Age Affected

Current age or age at death

Health Problem

Healthy

Living / Dead

Living

Your Brother 2

Question

Response

Comment/Age Affected

Current age or age at death

Health Problem

Healthy

Living / Dead

Living

Your Brother 3

Question

Response

Comment/Age Affected

Current age or age at death

Health Problem

Healthy

Living / Dead

Living

Sister(s)

Your Sister 1

Question

Response

Comment/Age Affected

Current age or age at death

Health Problem

Healthy

Living / Dead

Living

Your Sister 2

Question

Response

Comment/Age Affected

Current age or age at death

Health Problem

Healthy

Living / Dead

Living

Your Mother's Father

Question

Response

Comment/Age Affected

Current age or age at death

Health Problem

Heart attack	81
Died of natural causes	93

Living / Dead

Dead

Your Mother's Mother

Question

Response

Comment/Age Affected

Current age or age at death

Health Problem

Died of natural causes

Living / Dead

Dead

Your Mother's Brothers 1

Question

Response

Comment/Age Affected

Current age or age at death

Health Problem

Healthy

Living / Dead

Living

Your Father's Father

Question

Response

Comment/Age Affected

Current age or age at death

Health Problem

Heart attack	65
Died of natural causes	75

Living / Dead

Dead

Your Father's Mother

Question

Response

Comment/Age Affected

Current age or age at death

Health Problem

Healthy

Living / Dead

Living

Your Father's Sisters 1

Question

Response

Comment/Age Affected

Current age or age at death

Health Problem

Healthy

Living / Dead

Living

Your Father's Sisters 2

Question

Response

Comment/Age Affected

Current age or age at death

Health Problem

Healthy

Living / Dead

Living

Your Father's Sisters 3

Question

Response

Comment/Age Affected

Current age or age at death

Health Problem

Rhabdomysarcoma - soft tissue tumor

Living / Dead

Dead

Your Father's Brothers 1

Question

Response

Comment/Age Affected

Current age or age at death

Health Problem

Healthy

Living / Dead

Living