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: | 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: | Surgery - Age 4, left eye Blepharoplasty |
| Hospitalization other than surgery: Age & type of illness: | N/A |
| Have you ever had any broken bones? If yes, please give age and description: | No |
| 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: | N/A |
| 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: | Probiotics: taken 2x daily; Creatine HCl supplement: taken 2x daily; Whey protein supplement: taken 1x daily; Tart cherry supplement: taken 1x daily; Fish oil supplement: taken 1x daily; |
| List all current medication or treatments (include vitamins, aspirin, antacids, laxatives, herbal, sports supplements, etc.) Include drug, frequency and duration taken, and reason: | Probiotics: taken 2x daily; Creatine HCl supplement: taken 2x daily; Whey Protein supplement: taken 1x daily; Tart cherry supplement: taken 1x daily; Fish Oil supplement: taken 1x 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: | 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 - 2013, 2014 (x2), 2016, 2017 (x2) |
| 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 | 45 |
| 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 | 49 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Heart blockage
43
Double bypass
Obesity
43
Lapband procedure
Encephalopathy (mild)
40
From military injury, no treatment
Brothers
Your Brother 1
| Question | Response |
| Current age or age at death | 18 |
| 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 | 10 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Your Brother 3
| Question | Response |
| Current age or age at death | 8 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Your Brother 4
| Question | Response |
| Current age or age at death | 5 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Your Brother 5
| Question | Response |
| Current age or age at death | 2 |
| 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 | 15 |
| 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 | 4 |
| 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 | 56 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Lung Cancer |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Lung Cancer
54
Smoker, not treated
Your Mother's Mother
| Question | Response |
| Current age or age at death | 65 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Your Mother's Sisters 1
| Question | Response |
| Current age or age at death | 48 |
| 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 | 75 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Heart failure |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Heart Failure
75
No treatment, passed in sleep
Your Father's Mother
| 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