Personal Behavior History
Question | Response |
Current alcohol use: If yes, oz./week and type of alcohol: | Never |
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 |
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: | Septoplasty (age 23), tympanoplasty (age 18), tubes (ears) (4-7) |
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 - Fractured Wrist on snowboard (age 11) |
Have you ever had any serious illnesses? If yes, please give age and description: | Yes - Staph Infection (age 14) from dirty lake water |
How many days in the past 12 months could you not work because of all illness (colds, flu, accidents, surgery, etc)? Please describe: | 2 - Septoplasty |
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: | Creatine Monohydrate as supplement taken for 2 months, Hydrocodone (after septoplasty) for 10 days |
List all current medication or treatments (include vitamins, aspirin, antacids, laxatives, herbal, sports supplements, etc.) Include drug, frequency and duration taken, and reason: | Tylenol, Pepto Bismol, NyQuil (3-4 times a year), Ibuprofen (2-3 times a month) |
Do you wear glasses or contact lenses? Are you near or far-sighted? | No |
Usual weight? | 199 |
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 |
How many sexual partners do you currently have? | 0 |
Have you ever had a tattoo? If yes, what year did you get the tattoo? | Yes - Right shoulder (2017) |
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 | 52 |
Living / Dead | Living |
Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Your Father
Question | Response |
Current age or age at death | 57 |
Living / Dead | Living |
Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Sisters
Your Sister 1
Question | Response |
Current age or age at death | 26 |
Living / Dead | Living |
Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Your Sister 2
Question | Response |
Current age or age at death | 20 |
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 | 71 |
Living / Dead | Dead |
Cause of death and any treatment prior to death | Stroke |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Stroke (Smoker)
71
None-fatal
Your Mother's Mother
Question | Response |
Current age or age at death | 80 |
Living / Dead | Dead |
Cause of death and any treatment prior to death | Heart Attack |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
None noted but was a smoker
80
Hospice care
Your Mother's Sisters 1
Question | Response |
Current age or age at death | 68 |
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 | 59 |
Living / Dead | Living |
Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Your Father's Father
Question | Response |
Current age or age at death | 67 |
Living / Dead | Dead |
Cause of death and any treatment prior to death | Pulmonary Fibrosis |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Pulmonary Fibrosis (smoker and factory worker)
67
No treatment
Your Father's Mother
Question | Response |
Current age or age at death | 90 |
Living / Dead | Living |
Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Your Father's Sisters 1
Question | Response |
Current age or age at death | 0 |
Living / Dead | Dead |
Cause of death and any treatment prior to death | SIDS |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
No health issues prior to death
None
Your Father's Sisters 2
Question | Response |
Current age or age at death | 53 |
Living / Dead | Dead |
Cause of death and any treatment prior to death | Brain aneurysm |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Brain aneurysm
53
No treament
Your Father's Sisters 3
Question | Response |
Current age or age at death | 60 |
Living / Dead | Living |
Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy