Personal Behavior History
Donor Sexual History
Donor Genetic History
Donor Medical History
Family Medical HistoryPersonal Behavior History
| Question | Response |
| Current alcohol use: If yes, oz./week and type of alcohol: | Regularly - 48-72 oz. beer/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? | 5 years ago |
| For how many years? | 12 |
| 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
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 for at least 97 mutations |
| 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 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? | 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 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 | None |
| Congenital heart disease | None |
| Hemophilia/bleeding problem | None |
| Emphysema | None |
| Cystic Fibrosis | None |
| Alpha-1 Antitrypsin Deficiency | None |
| Pyloric stenosis | None |
| Colon cancer | None |
| Inflammatory bowel disease | None |
| Irritable Bowel Syndrome | Self - age 25, treated with medication (no longer needed) |
| Diabetes mellitus requiring insulin therapy | None |
| Diabetes mellitus not requiring insulin therapy | Grandparent - Paternal grandmother, age 45, treats with oral medication |
| 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 - as a teenager, no treatment necessary; Sibling - Brother, as a teenager, no treatment necessary |
| 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: | Stitches in hand and stomach, skin graft, at age 1, accidental electrocution |
| 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 - Fibula broken at age 5 due to playground 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: | 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: | Advil and aspirin occasionally due to colds or headaches |
| 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 |
| Usual weight? | 172 |
| Recent weight loss or gain? # of lbs and reason: | No |
| Allergies (medicines, food, pollens)? If yes, please list substance and reaction caused: | Yes - Pollen, dust; seasonal: Runny nose |
| 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 HistorySee list of questions asked here
Your Mother
| Question | Response | Comment/Age Affected |
| Current age or age at death | 60 | |
| Health Problem | Hypothyroidism, treats with medication | 45 |
| Osteoporosis, treats with medication | 47 | |
| Living / Dead | Living |
Your Father
| Question | Response | Comment/Age Affected |
| Current age or age at death | 60 | |
| Health Problem | High cholesterol, treats with statins | 55 |
| Living / Dead | Living |
Brothers
Your Brother 1
| Question | Response | Comment/Age Affected |
| Current age or age at death | 32 | |
| Health Problem | Healthy | |
| Living / Dead | Living |
Sons
Your Son 1
| Question | Response | Comment/Age Affected |
| Current age or age at death | 11 | |
| Health Problem | Healthy | |
| Living / Dead | Living |
Your Son 2
| Question | Response | Comment/Age Affected |
| Current age or age at death | 1 | |
| Health Problem | Healthy | |
| Living / Dead | Living |
Your Mother's Father
| Question | Response | Comment/Age Affected |
| Current age or age at death | 80 | |
| Health Problem | Asthma, age of onset and treatment (if any) unknown | |
| Bronchial pneumonia, treated in hospital | 80 | |
| Cause of death: Complications of pneumonia | 80 | |
| Living / Dead | Dead |
Your Mother's Mother
| Question | Response | Comment/Age Affected |
| Current age or age at death | 52 | |
| Health Problem | Breast cancer, no treatment received | 51 |
| Cause of death: Breast cancer | 52 | |
| Living / Dead | Dead |
Your Mother's Sisters 1
| Question | Response | Comment/Age Affected |
| Current age or age at death | 64 | |
| Health Problem | Healthy | |
| Living / Dead | Living |
Your Mother's Sisters 2
| Question | Response | Comment/Age Affected |
| Current age or age at death | 55 | |
| Health Problem | Healthy | |
| Living / Dead | Living |
Your Mother's Sisters 3
| Question | Response | Comment/Age Affected |
| Current age or age at death | 47 | |
| Health Problem | Healthy | |
| Living / Dead | Living |
Your Mother's Brothers 1
| Question | Response | Comment/Age Affected |
| Current age or age at death | 66 | |
| Health Problem | Healthy | |
| Living / Dead | Living |
Your Father's Father
| Question | Response | Comment/Age Affected |
| Current age or age at death | 67 | |
| Health Problem | Healthy | |
| Cause of death: Automobile accident | 67 | |
| Living / Dead | Dead |
Your Father's Mother
| Question | Response | Comment/Age Affected |
| Current age or age at death | 86 | |
| Health Problem | Diabetes type II, treats with oral medication | 45 |
| Living / Dead | Living |
Your Father's Sisters 1
| Question | Response | Comment/Age Affected |
| Current age or age at death | 66 | |
| Health Problem | Healthy | |
| Living / Dead | Living |
Your Father's Sisters 2
| Question | Response | Comment/Age Affected |
| Current age or age at death | 46 | |
| Health Problem | Healthy | |
| Living / Dead | Living |