Personal Behavior History
Donor Sexual History
Donor Genetic History
Donor Medical History
Family Medical HistoryUpdated medical information on the donor and his family (if applicable) will be included at the bottom of the Summary Profile
Personal Behavior History
| Question | Response |
| Current alcohol use: If yes, oz./week and type of alcohol: | Frequently - 12-24 oz beer twice per 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 |
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: | Surgery on broken nose age 10; wisdom teeth (4) removal age 21; surgery to fix labrum/rotator cuff from car accident age 37 |
| Hospitalization other than surgery: Age & type of illness: | None |
| Have you ever had any broken bones? If yes, please give age and description: | Yes - Broke right wrist age 7, sports related injury; Broken nose age 10, sports related injury; Fractured Sternum age 37, car 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: | 240 - Out on workers compensation since car accident resulted in torn Labrum/Rotator Cuff. |
| Are you presently under a physician's care for any reason? If yes, please describe: | Yes - Currently receiving care for torn Labrum/Rotator cuff. |
| 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: | Garcinia Combogia 1000 mg 4 times daily since August 2019 for health; Dandelion Root 500 mg 2 times daily since August 2019 for health; Maca 500 mg 2 times daily since September 2017 for health; L-Arginine 400 mg 2 times daily since September 2017 for health; L-Lysine 2000 mg 2 times daily since September 2017 for health; Ashwagandha 450 mg 1 time daily since September 2017 for health; Nettle leaf 870 mg 1 time daily since September 2017 for health; Meloxicam 15 mg daily for 30 days in April 2019 for pain management prior to surgery; Methocarbam 500 mg for 30 days in April 2019 for pain management; Celecoxib 200 mg twice daily from August to September 2019; Gabapentin 100 mg three times daily from January to March 2020 for pain after surgery; Naproxen sodium 550 mg twice dialy from March to July 2020 for shoulder pain; Gabapentin 300 mg three times daily from July 2020 to present for pain management. |
| List all current medication or treatments (include vitamins, aspirin, antacids, laxatives, herbal, sports supplements, etc.) Include drug, frequency and duration taken, and reason: | Garcinia Combogia 1000 mg 4 times daily since August 2019 for health; Dandelion Root 500 mg 2 times daily since August 2019 for health; Maca 500 mg 2 times daily since September 2017 for health; L-Arginine 400 mg 2 times daily since September 2017 for health; L-Lysine 2000 mg 2 times daily since September 2017 for health; Ashwagandha 450 mg 1 time daily since September 2017 for health; Nettle leaf 870 mg 1 time daily since September 2017 for health; Gabapentin 300 mg three times daily from July 2020 to present for pain management. |
| Do you wear glasses or contact lenses? Are you near or far-sighted? | No |
| Usual weight? | 175 |
| 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? | No |
| Have you ever had your ear(s) or body pierced? If yes, where and what year? | Yes - Ear, 2020 |
Family Medical HistorySee list of questions asked here
Your Mother
| 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 Father
| Question | Response |
| Current age or age at death | 74 |
| 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
65
Lisinopril 20 mg daily
Seasonal Allergies
22
No treatment
Brothers
Your Brother 1
| Question | Response |
| Current age or age at death | 47 |
| 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 | 36 |
| 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 | 49 |
| 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 | 40 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Sons
Your Son 1
| Question | Response |
| Current age or age at death | 4 |
| Living / Dead | Living |
Health Problems
Healthy
Daughters
Your Daughter 1
| Question | Response |
| Current age or age at death | 8 |
| Living / Dead | Living |
Health Problems
Healthy
Your Mother's Father
| Question | Response |
| Current age or age at death | 92 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Heart Attack |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Broken collar bone due to fall
84
No treatment
Heart Attack
92
None, fatal
Your Mother's Mother
| Question | Response |
| Current age or age at death | 90 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Heart attack |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Heart Attack
90
None, fatal
Your Mother's Sisters 1
| 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
Healthy
Your Mother's Sisters 2
| Question | Response |
| Current age or age at death | 5 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Seizures caused by birth trauma |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Nuchal cord birth injury
No treatment
Your Mother's Brothers 1
| Question | Response |
| Current age or age at death | 67 |
| 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 | 64 |
| 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 | 79 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Fall in apartment |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Idiopathic thrombocytopenic pupura
79
No treatment, diagnosed post mortem
Your Father's Mother
| Question | Response |
| Current age or age at death | 78 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Heart attack |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Breast cancer
68
Mastectomy
Breast cancer recurrence
78
No treatment
Your Father's Sisters 1
| Question | Response |
| Current age or age at death | 82 |
| 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 | 54 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Ovarian cancer |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Ovarian cancer
54
No treatment
Your Father's Brothers 1
| Question | Response |
| Current age or age at death | 67 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy