| Cryogenic Laboratories, Inc. |
| Donor 2681 Medical Profile |
| Questions |
| Personal Behavior History |
| Donor Genetic History |
| Donor Medical History |
| Family Medical History |
| Personal Behavior History | ||
| Question | Response | |
| Alcohol use: If yes, oz./week and type of alcohol: | Occasionally - 12 oz beer/week | |
| Do you or any of your relatives have a history of alcoholism or alcohol abuse? 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 | |
| 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 | |
| A person having intravenous, intramuscular, or subcutaneous injection of drugs not prescribed by a licensed physician for medical purposes? | No | |
| Have you: | ||
| Question | Response | |
| 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 the 97 mutations tested | |
| Have you been tested for Alpha-1 Antitrypsin Disorder? If yes, the result: | No | |
| Have you had any additional genetic testing? If yes, complete the following: | Yes - Karyotype | |
| 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: If yes, result(s): | N/A | |
| Niemann-Pick: 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 | |
| BRCA1/BRCA2 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 thalassemia? | Yes - Standard donor screening | |
| 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 - Maternal grandfather age 72, Maternal grandmother age 74 |
|
| Congenital heart disease | None |
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| Hemophilia/bleeding problem | None |
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| Severe bleeding tendency | None |
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| Cystic Fibrosis | None |
|
| Alpha-1 Antitrypsin Disorder | None |
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| Pyloric stenosis | None |
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| Inflammatory bowel disease | None |
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| Diabetes mellitus requiring insulin therapy. | None |
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| Diabetes mellitus not requiring insulin therapy. | None |
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| PKU or inherited metabolism disorder | None |
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| Progressive kidney disease | None |
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| Polycystic kidney disease | None |
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| Miscarriages or stillborn | None |
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| Herpes simplex virus, genital | None |
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| Migraines | Self - Donor during puberty, no longer experiences |
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| Mental retardation | None |
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| Senility or mental deterioration before age 60 | None |
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| Epilepsy/seizures | None |
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| Neural tube defects - open spine or hypocephalus/water on the brain | None |
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| Huntington's disease | None |
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| Tuberous sclerosis | None |
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| Neurofibromatosis | None |
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| Parkinson's disease | None |
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| Down's syndrome/Mongolism | None |
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| Autism | None |
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| Autism Spectrum Disorder | None |
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| PDD (pervasive developmental delay) | None |
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| Asperger's Syndrome | None |
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| Schizophrenia | None |
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| Manic depressive psychosis | None |
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| Muscular dystrophy | None |
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| Loss of muscle coordination | None |
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| Rheumatoid arthritis | None |
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| Reiter's disease | None |
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| Club foot | None |
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| Deafness before age of 60 | None |
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| Cataracts before age of 60 | None |
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| Blindness in both eyes before age of 60 | None |
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| Glaucoma | None |
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| Psoriasis | None |
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| Albinism | None |
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| More than 5 purple or coffee-colored spots on the skin (size of a quarter or larger) | None |
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| Drug abuse, misuse, or addiction | None |
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| Cleft palate or cleft lip | None |
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| Serious birth defects | None |
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| Inguinal hernia | None |
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| Premature degeneration of any organ system | None |
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| The same cancer in more than one family member | Grandparent - Lung cancer - Paternal grandfather, age 76; Paternal grandmother, age 78 (both smokers) |
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| Donor Medical History | ||
| Question | Response | |
| List any operations: Age & reason: | None | |
| Hospitalization other than surgery: Age & type of illness: | None | |
| 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: | 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: | 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? | Yes - Near sighted | |
| Usual weight? | 172 | |
| Recent loss or gain? # of lbs and reason: | No | |
| Allergies (medicines, food, pollens)? If yes, please list substance and reaction caused: | Yes - Very fine cat hair causes sneezing | |
| Have you been exposed to, or been at risk of exposure to: radiation, chemicals, or toxic amounts of lead, mercury, or gold? If yes, please describe: | No | |
| Have you been permanently excluded or deferred from donating blood or plasma? If yes, when and why? | No | |
| Have you been tested for HIV (AIDS)? If yes, when: | Yes - Negative, ongoing donor screening | |
| Sexual orientation: | Heterosexual | |
| Number of current sexual partners: | 0 | |
| Have you had a partner who has had cultures of Trichomonas? 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 - 1993 | |
| Have you ever had your ear(s) or body pierced? If yes, where and what year? | Yes - Ear, 1990 | |
| 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 | |
| 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 | 69 | | Health Problem |
Living / Dead | Living | |
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Your Father| Question | Response | Comment/Age Affected | Current age or age at death | 69 | | Health Problem |
Living / Dead | Living | |
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| Brother(s) |
Your Brother 1| Question | Response | Comment/Age Affected | Current age or age at death | 41 | | Health Problem |
Living / Dead | Living | | | ||||||
Your Brother 2| Question | Response | Comment/Age Affected | Current age or age at death | 28 | | Health Problem |
Living / Dead | Living | |
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| Sister(s) |
Your Sister 1| Question | Response | Comment/Age Affected | Current age or age at death | 39 | | Health Problem |
Living / Dead | Living | |
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| Son(s) |
Your Son 1| Question | Response | Comment/Age Affected | Current age or age at death | 10 | | Health Problem |
Living / Dead | Living | |
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| Daughter(s) |
Your Daughter 1| Question | Response | Comment/Age Affected | Current age or age at death | 7 | | Health Problem |
Living / Dead | Living | |
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Your Mother's Father| Question | Response | Comment/Age Affected | Current age or age at death | 72 | | Health Problem |
Living / Dead | Dead | |
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Your Mother's Mother| Question | Response | Comment/Age Affected | Current age or age at death | 74 | | Health Problem |
Living / Dead | Dead | |
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Your Mother's Sisters 1| Question | Response | Comment/Age Affected | Current age or age at death | 67 | | Health Problem |
Living / Dead | Living | | | ||||||
Your Mother's Sisters 2| Question | Response | Comment/Age Affected | Current age or age at death | 58 | | Health Problem |
Living / Dead | Living | |
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Your Mother's Brothers 1| Question | Response | Comment/Age Affected | Current age or age at death | 65 | | Health Problem |
Living / Dead | Living | | | ||||||
Your Mother's Brothers 2| Question | Response | Comment/Age Affected | Current age or age at death | 62 | | Health Problem |
Living / Dead | Living | | | ||||||
Your Mother's Brothers 3| Question | Response | Comment/Age Affected | Current age or age at death | 60 | | Health Problem |
Living / Dead | Living | | | ||||||
Your Mother's Brothers 4| Question | Response | Comment/Age Affected | Current age or age at death | 56 | | Health Problem |
Living / Dead | Living | |
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Your Father's Father| Question | Response | Comment/Age Affected | Current age or age at death | 76 | | Health Problem |
Living / Dead | Dead | |
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Your Father's Mother| Question | Response | Comment/Age Affected | Current age or age at death | 78 | | Health Problem |
Living / Dead | Dead | |
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Your Father's Sisters 1| Question | Response | Comment/Age Affected | Current age or age at death | 65 | | Health Problem |
Living / Dead | Living | |
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Your Father's Brothers 1| Question | Response | Comment/Age Affected | Current age or age at death | 72 | | Health Problem |
Living / Dead | Living | | | ||||||
Your Father's Brothers 2| Question | Response | Comment/Age Affected | Current age or age at death | 67 | | Health Problem |
Living / Dead | Living | |
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