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: | Occasionally - Less than 4 oz. wine/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? | 0 |
| 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 the 147 mutations tested |
| 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 - for mutations 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): | Yes - Non-carrier for mutations tested |
| Gaucher: If yes, result(s): | Yes - Non-carrier for mutations tested |
| Canavan: If yes, result(s): | Yes - Non-carrier for mutations tested |
| Fanconi Anemia Type C: If yes, result(s): | Yes - Non-carrier for mutations tested |
| Niemann-Pick Type A: If yes, result(s): | Yes - Non-carrier for mutations tested |
| Bloom Syndrome: If yes, result(s): | Yes - Non-carrier for mutations tested |
| Familial Dysautonomia: If yes, result(s): | Yes - Non-carrier for mutations tested |
| Mucolipidosis IV: If yes, result(s): | Yes - Non-carrier for mutations tested |
| Maple Syrup Urine Disease 1B: If yes, result(s): | Yes - Non-carrier for mutations tested |
| Usher Syndrome III & 1F: If yes, result(s): | Yes - Non-carrier for mutations tested |
| Glycogen Storage Disease 1A: If yes, result(s): | Yes - Non-carrier for mutations tested |
| ABCC8-Related Hyperinsulinism: If yes, result(s): | Yes - Non-carrier for mutations tested |
| BRCA1/BRCA2: If yes, result(s): | No |
| Lipoamide Dehydrogenase Deficiency: If yes, result(s): | Yes - Non-carrier for mutations tested |
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: | 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 | None |
| Diabetes mellitus requiring insulin therapy | None |
| Diabetes mellitus not requiring insulin therapy | Grandparent - Paternal grandfather, age 65 |
| 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, mild, treated with over-the-counter medication |
| 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: | Knee ACL repair at age 12, fell from stair railing; Shoulder ligament repair at age 18, sports injury |
| 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 - Knee, age 12 fell from stair railing |
| 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: | 2 - Sinus infection |
| 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: | Multivitamin and fish oil, taken daily; Creatine, taken infrequently after workouts; Aspirin, taken as needed 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: | Multivitamin and fish oil, taken daily |
| Do you wear glasses or contact lenses? Are you near or far-sighted? | No - (Near-sighted before laser surgery) |
| Usual weight? | 177 |
| Recent weight loss or gain? # of lbs and reason: | No |
| Allergies (medicines, food, pollens)? If yes, please list substance and reaction caused: | No - Seasonal pollens, Cat hair: Cause itchy, watery eyes, sneezing |
| 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? | 0 |
| 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 | 59 | |
| Health Problem | Osteoarthritis, mild, no treatment | 50 |
| Living / Dead | Living |
Your Father
| Question | Response | Comment/Age Affected |
| Current age or age at death | 62 | |
| Health Problem | Healthy | |
| Living / Dead | Living |
Brothers
Your Brother 1
| Question | Response | Comment/Age Affected |
| Current age or age at death | 32 | |
| Health Problem | Healthy | |
| Seasonal allergies, treated with over-the-counter medication | 5 | |
| Living / Dead | Living |
Your Mother's Father
| Question | Response | Comment/Age Affected |
| Current age or age at death | 88 | |
| Health Problem | Pneumonia, treated in hospital | 88 |
| Cause of death: Complications of pneumonia | 88 | |
| Living / Dead | Dead |
Your Mother's Mother
| Question | Response | Comment/Age Affected |
| Current age or age at death | 85 | |
| Health Problem | Osteoporosis, no treatment | 70 |
| Cause of death: Head trauma (she fell and hit her head) | 85 | |
| Living / Dead | Dead |
Your Mother's Sisters 1
| Question | Response | Comment/Age Affected |
| Current age or age at death | 65 | |
| Health Problem | Healthy | |
| Living / Dead | Living |
Your Mother's Brothers 1
| Question | Response | Comment/Age Affected |
| Current age or age at death | 67 | |
| Health Problem | Unknown | |
| Living / Dead | Living |
Your Mother's Brothers 2
| Question | Response | Comment/Age Affected |
| Current age or age at death | 62 | |
| Health Problem | Unknown | |
| Living / Dead | Living |
Your Mother's Brothers 3
| Question | Response | Comment/Age Affected |
| Current age or age at death | 57 | |
| Health Problem | Unknown | |
| Living / Dead | Living |
Your Father's Father
| Question | Response | Comment/Age Affected |
| Current age or age at death | 88 | |
| Health Problem | Obesity, age of onset unknown, no treatment | |
| Diabetes, treated with medication | 65 | |
| High blood pressure, treated with medication | 65 | |
| Pneumonia, treated in hospital | 88 | |
| Cause of death: Pneumonia | 88 | |
| Living / Dead | Dead |
Your Father's Mother
| Question | Response | Comment/Age Affected |
| Current age or age at death | 83 | |
| Health Problem | Cataract, treated with surgery | 60 |
| Osteoporosis, no treatment | 70 | |
| Broken hip in a fall, treated with hip replacement surgery | 73 | |
| Living / Dead | Living |
Your Father's Sisters 1
| Question | Response | Comment/Age Affected |
| Current age or age at death | 58 | |
| Health Problem | Healthy | |
| Living / Dead | Living |
Your Father's Brothers 1
| Question | Response | Comment/Age Affected |
| Current age or age at death | 59 | |
| Health Problem | Healthy | |
| Cause of death: Car accident | 59 | |
| Living / Dead | Dead |
Your Father's Brothers 2
| Question | Response | Comment/Age Affected |
| Current age or age at death | 60 | |
| Health Problem | Unknown | |
| Living / Dead | Living |