Personal Behavior History
Donor Sexual History
Donor Genetic History
Donor Medical History
Family Medical HistoryThis donor is a healthy carrier for a genetic disease.
Please see his Genetic Testing Summary and Acknowledgment of Genetic Risk for details
Please see his Genetic Testing Summary and Acknowledgment of Genetic Risk for details
Personal Behavior History
| Question | Response |
| Current alcohol use: If yes, oz./week and type of alcohol: | Occasionally - 12 oz. beer/week |
| 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? | N/A |
| 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 - But no high fructose corn syrup or processed sugars (by choice) |
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 |
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 by gene sequencing |
| 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 |
| 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 |
Donor Medical History
| Question | Response |
| List any operations: Age & reason: | None |
| 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 - Tibia, age 12, 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: | 1 - Cold |
| 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, cranberry, zinc, fish oil, all taken daily |
| List all current medication or treatments (include vitamins, aspirin, antacids, laxatives, herbal, sports supplements, etc.) Include drug, frequency and duration taken, and reason: | Multivitamin, cranberry, zinc, fish oil, all taken daily |
| Do you wear glasses or contact lenses? Are you near or far-sighted? | No |
| Usual weight? | 150 |
| Recent weight loss or gain? # of lbs and reason: | No |
| Allergies (medicines, food, pollens)? If yes, please list substance and reaction caused: | Yes - Ragweed: Causes sneezing, congestion |
| Have you been tested for HIV (AIDS)? If yes, when: | Yes - Negative, ongoing donor screening |
| 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 |
| Current age or age at death | 66 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Hyperthyroidism
55
Surgery
Your Father
| Question | Response |
| Current age or age at death | 69 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Knee damage (sports-related)
49
Knee replacement surgery
Brothers
Your Brother 1
| Question | Response |
| Current age or age at death | 40 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Your Brother 2
| Question | Response |
| Current age or age at death | 38 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Your Mother's Father
| Question | Response |
| Current age or age at death | 73 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Heart failure |
Health Problems
Healthy
Your Mother's Mother
| Question | Response |
| Current age or age at death | 96 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Congestive heart failure |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Congestive heart failure
94
Hospitalization
Your Mother's Sisters 1
| Question | Response |
| Current age or age at death | 71 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Your Mother's Sisters 2
| Question | Response |
| Current age or age at death | 70 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Your Mother's Sisters 3
| Question | Response |
| Current age or age at death | 69 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Epilepsy (medication no longer taken due to side effects)
59
None
Your Mother's Brothers 1
| Question | Response |
| Current age or age at death | 73 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Hemorrhoids
65
Surgery
Your Mother's Brothers 2
| Question | Response |
| Current age or age at death | 72 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Polio
4
Physical therapy
Your Father's Father
| Question | Response |
| Current age or age at death | 55 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Heart attack |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Heart attack, fatal
55
None
Your Father's Mother
| Question | Response |
| Current age or age at death | 97 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Organ failure |
Health Problems
Healthy
Your Father's Sisters 1
| Question | Response |
| Current age or age at death | 75 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Lung cancer |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Lung cancer (smoker)
73
None
Your Father's Sisters 2
| Question | Response |
| Current age or age at death | 76 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Lung cancer |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Lung cancer (smoker)
71
Chemotherapy, Radiation
Your Father's Sisters 3
| Question | Response |
| Current age or age at death | 72 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Your Father's Brothers 1
| Question | Response |
| Current age or age at death | 72 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Diabetes not requiring insulin therapy, in his early 50s
Medication