Donor 5411 - Medical Profile

Personal Behavior History

Question	Response
Current alcohol use: If yes, oz./week and type of alcohol:	Frequently - 32 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:	Yes - 1 cigarette/month, 2 years
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 by gene sequencing
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 - by gene sequencing

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 by gene sequencing
Gaucher: If yes, result(s):	Yes - Non-carrier for mutations tested
Canavan: If yes, result(s):	Yes - Non-carrier by gene sequencing
Fanconi Anemia Type C: If yes, result(s):	Yes - Non-carrier by gene sequencing
Niemann-Pick Type A: If yes, result(s):	Yes - Non-carrier by gene sequencing
Bloom Syndrome: If yes, result(s):	Yes - Non-carrier by gene sequencing
Familial Dysautonomia: If yes, result(s):	Yes - Non-carrier by gene sequencing
Mucolipidosis IV: If yes, result(s):	Yes - Non-carrier by gene sequencing
Maple Syrup Urine Disease 1B: If yes, result(s):	Yes - Non-carrier by gene sequencing
Usher Syndrome III & 1F: If yes, result(s):	Yes - Non-carrier by gene sequencing
Glycogen Storage Disease 1A: If yes, result(s):	Yes - Non-carrier by gene sequencing
ABCC8-Related Hyperinsulinism: If yes, result(s):	Yes - Non-carrier by gene sequencing
BRCA1/BRCA2: If yes, result(s):	No
Lipoamide Dehydrogenase Deficiency: If yes, result(s):	Yes - Non-carrier by gene sequencing

Ancestry

Question	Response
Are you of African ancestry?	No
If yes, have you been tested as a carrier of sickle cell anemia?	Yes
If yes, result:	Non Carrier - by gene sequencing
Are you of Mediterranean, Greek or Italian ancestry?	No
If yes, have you been tested as a carrier of beta thalassemia?	Yes
If yes, result:	Non Carrier - by gene sequencing

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	Aunt/Uncle - Maternal uncle #1, age 61, cause of death; Maternal uncle #2, age 58, cause of death
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	Grandparent - Paternal grandfather, age 65; Paternal grandmother, age 49
Diabetes mellitus not requiring insulin therapy	Mother - age 53
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	None
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:	Leg surgery at age 6, both legs broken in a car accident
Hospitalization other than surgery: Age & type of illness:	No
Have you ever had any broken bones? If yes, please give age and description:	Yes - Both legs, age 6
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:	1 - Flu
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:	Fish oil, taken daily; Glucosamine, taken three times per week; Vitamin D, taken twice per week
List all current medication or treatments (include vitamins, aspirin, antacids, laxatives, herbal, sports supplements, etc.) Include drug, frequency and duration taken, and reason:	Fish oil, taken daily; Glucosamine, taken three times per week; Vitamin D, taken twice per week
Do you wear glasses or contact lenses? Are you near or far-sighted?	Yes - Near-sighted
Usual weight?	240
Recent weight loss or gain? # of lbs and reason:	No
Allergies (medicines, food, pollens)? If yes, please list substance and reaction caused:	No
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?	N/A
Have you ever had a tattoo? If yes, what year did you get the tattoo?	Yes - 2015
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	60
Health Problem	Type II Diabetes not requiring insulin therapy, treated with medication	53
Living / Dead	Living

Your Father

Question	Response	Comment/Age Affected
Current age or age at death	63
Health Problem	Healthy
Living / Dead	Living

Brothers

Your Brother 1

Question	Response	Comment/Age Affected
Current age or age at death	31
Health Problem	Healthy
Living / Dead	Living

Sisters

Your Sister 1

Question	Response	Comment/Age Affected
Current age or age at death	34
Health Problem	Healthy
Living / Dead	Living

Your Mother's Father

Question	Response	Comment/Age Affected
Current age or age at death	65
Health Problem	Cancer, unknown type, no treatment	65
Health Problem	Cause of death: Cancer	65
Living / Dead	Dead

Your Mother's Mother

Question	Response	Comment/Age Affected
Current age or age at death	55
Health Problem	Cancer, unknown type, no treatment	55
Health Problem	Cause of death: Cancer	55
Living / Dead	Dead

Your Mother's Sisters 1

Question	Response	Comment/Age Affected
Current age or age at death	72
Health Problem	Healthy
Living / Dead	Living

Your Mother's Sisters 2

Question	Response	Comment/Age Affected
Current age or age at death	63
Health Problem	Healthy
Living / Dead	Living

Your Mother's Sisters 3

Question	Response	Comment/Age Affected
Current age or age at death	56
Health Problem	Healthy
Living / Dead	Living

Your Mother's Brothers 1

Question	Response	Comment/Age Affected
Current age or age at death	61
Health Problem	Heart attack, fatal, no treatment	61
Health Problem	Cause of death: Heart attack	61
Living / Dead	Dead

Your Mother's Brothers 2

Question	Response	Comment/Age Affected
Current age or age at death	58
Health Problem	Heart attack, fatal, no treatment	58
Health Problem	Cause of death: Heart attack	58
Living / Dead	Dead

Your Mother's Brothers 3

Question	Response	Comment/Age Affected
Current age or age at death	67
Health Problem	Healthy
Living / Dead	Living

Your Father's Father

Question	Response	Comment/Age Affected
Current age or age at death	85
Health Problem	Type II Diabetes requiring insulin therapy	65
Living / Dead	Living

Your Father's Mother

Question	Response	Comment/Age Affected
Current age or age at death	83
Health Problem	Type II Diabetes requiring insulin therapy	49
Living / Dead	Living

Your Father's Sisters 1

Question	Response	Comment/Age Affected
Current age or age at death	59
Health Problem	Healthy
Living / Dead	Living

Your Father's Sisters 2

Question	Response	Comment/Age Affected
Current age or age at death	56
Health Problem	Healthy
Living / Dead	Living

Your Father's Sisters 3

Question	Response	Comment/Age Affected
Current age or age at death	51
Health Problem	Healthy
Living / Dead	Living

Your Father's Brothers 1

Question	Response	Comment/Age Affected
Current age or age at death	65
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

Donor Number: 5411

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