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: | 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 karotype |
| Spinal Muscular Atrophy (SMA)? If yes, the result: | Non Carrier - by gene sequencing |
| 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: | Left finger at 16; Nose at 24 - Left finger slammed in door at age 16, Broken nose surgery at age 24 from altercation at age 15 |
| 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 - Nose at age 15 |
| Have you ever had any serious illnesses? If yes, please give age and description: | Yes - Lymes disease, age 11 (antibiotic treatment) |
| 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: | Aspirin as needed for headaches; Antacid 1-2x/week for heartburn |
| List all current medication or treatments (include vitamins, aspirin, antacids, laxatives, herbal, sports supplements, etc.) Include drug, frequency and duration taken, and reason: | Antacid 1-2x/week for heartburn |
| Do you wear glasses or contact lenses? Are you near or far-sighted? | Yes - Near at age 10 |
| Usual weight? | 210 |
| 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? | 1 |
| Have you ever had a tattoo? If yes, what year did you get the tattoo? | Yes - Right shoulder, 2012 |
| Have you ever had your ear(s) or body pierced? If yes, where and what year? | Yes - Left ear, 2005 |
Family Medical HistorySee list of questions asked here
Your Mother
| Question | Response |
| Current age or age at death | 64 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Diabetes mellitus not requiring insulin therapy
50
Diet controlled
Your Father
| 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
Disease
Age Diagnosed
Treatment For Condition
High blood pressure
42
Diet controlled
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
Sisters
Your Sister 1
| Question | Response |
| Current age or age at death | 37 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Daughters
Your Daughter 1
| Question | Response |
| Current age or age at death | 7 |
| Living / Dead | Living |
Health Problems
Healthy
Your Daughter 2
| Question | Response |
| Current age or age at death | 4 |
| Living / Dead | Living |
Health Problems
Healthy
Your Daughter 3
| Question | Response |
| Current age or age at death | 2 |
| Living / Dead | Living |
Health Problems
Healthy
Your Mother's Father
| Question | Response |
| Current age or age at death | 63 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Cancer |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Lung cancer
62
No treatment, was smoker
Your Mother's Mother
| Question | Response |
| Current age or age at death | 85 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Heart Failure |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Congestive heart failure
85
No treatment
Your Mother's Sisters 1
| Question | Response |
| Current age or age at death | 66 |
| Living / Dead | Living - Twin to Brother #2 |
| 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 | 62 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Your Mother's Brothers 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 Brothers 2
| Question | Response |
| Current age or age at death | 66 |
| Living / Dead | Living - Twin to Sister #1 |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Your Mother's Brothers 3
| Question | Response |
| Current age or age at death | 54 |
| 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 | 52 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Accident |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Accident
52
No treatment
Your Father's Mother
| Question | Response |
| Current age or age at death | 58 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Heart Attack |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Heart attack
58
No treatment, immediately fatal
Your Father's Sisters 1
| Question | Response |
| Current age or age at death | 77 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Your Father's Sisters 2
| Question | Response |
| Current age or age at death | 80 |
| 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 | 73 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy