Donor 1886 - Medical Profile

Personal Behavior History

Question	Response
Current alcohol use: If yes, oz./week and type of alcohol:	N/A
Have you or any of your family members been diagnosed with alcoholism or drug addiction? If yes, relation and age affected:	N/A
Tobacco use: Do you smoke? If yes, #/day and for how long:	N/A
If you did smoke but quit, when did you last smoke?	N/A
For how many years?	N/A
Do you sleep well?	N/A
Do you exercise on regular basis?	N/A
Is your diet well balanced? If no, explain:	N/A
Are you a vegetarian?	N/A
Any dietary restrictions? If yes, explain:	N/A

Sexual History

Have you ever had sex with:

Question	Response
A partner whose sexual background you are unsure of in the past 12 months?	N/A
Another man anal or oral, even once, since 1977?	N/A

Donor Genetic History

Question	Response
Were you or any family members born with any birth defects? If yes, explain:	N/A
Have you been tested for Cystic Fibrosis? If yes, the result:	Yes - Non-carrier for the 86 mutations tested
Karyotype? If yes, the result:	Yes - Normal karyotype
Spinal Muscular Atrophy (SMA)? If yes, the result:	Unknown - Donor was not tested
Tay Sachs? If yes, the result:	Unknown - Donor was not tested

Ancestry

Question	Response
Are you of Jewish ancestry? If yes, please note: Ashkenazi, Sephardi, or Other	N/A

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):	N/A
Gaucher: If yes, result(s):	N/A
Canavan: If yes, result(s):	N/A
Fanconi Anemia Type C: If yes, result(s):	N/A
Niemann-Pick Type A: If yes, result(s):	N/A
Bloom Syndrome: If yes, result(s):	N/A
Familial Dysautonomia: If yes, result(s):	N/A
Mucolipidosis IV: If yes, result(s):	N/A
Maple Syrup Urine Disease 1B: If yes, result(s):	N/A
Usher Syndrome III & 1F: If yes, result(s):	N/A
Glycogen Storage Disease 1A: If yes, result(s):	N/A
ABCC8-Related Hyperinsulinism: If yes, result(s):	N/A
BRCA1/BRCA2: If yes, result(s):	N/A
Lipoamide Dehydrogenase Deficiency: If yes, result(s):	N/A

Ancestry

Question	Response
Are you of African ancestry?	No
If yes, have you been tested as a carrier of sickle cell anemia?	N/A
If yes, result:	Non Carrier
Are you of Mediterranean, Greek or Italian ancestry?	No
If yes, have you been tested as a carrier of beta thalassemia?	Yes - Standard donor screening
If yes, result:	Non Carrier

Have you or any member of your family had, currently have or been diagnosed with any of the following conditions? If yes, please list the affected individual(s), mother or father's side, age at onset, treatment and any other pertinent information.

Heart attack	Grandparent - Maternal grandmother, age 88
Congenital heart disease	N/A
Hemophilia/bleeding problem	N/A
Emphysema	N/A
Cystic Fibrosis	N/A
Alpha-1 Antitrypsin Deficiency	N/A
Pyloric stenosis	N/A
Colon cancer	N/A
Inflammatory bowel disease	N/A
Irritable Bowel Syndrome	N/A
Diabetes mellitus requiring insulin therapy	N/A
Diabetes mellitus not requiring insulin therapy	N/A
PKU or inherited metabolism disorder	N/A
Progressive kidney disease	N/A
Polycystic kidney disease	N/A
Miscarriages or stillborn	N/A
Herpes simplex virus, genital	N/A
Migraines	N/A
Mental retardation	N/A
Senility or mental deterioration before age 60	N/A
Epilepsy/seizures	N/A
Neural tube defects - open spine or hydrocephalus/water on the brain	N/A
Huntington's disease	N/A
Tuberous sclerosis	N/A
Neurofibromatosis	N/A
Parkinson's disease	N/A
Down Syndrome	N/A
Autism	N/A
Autism Spectrum Disorder	N/A
Pervasive Developmental Delay (PDD)	N/A
Asperger's Syndrome	N/A
Schizophrenia	N/A
Bipolar (manic depressive psychosis)	N/A
Attention Deficit Disorder (ADD)	N/A
Attention Deficit Hyperactivity Disorder (ADHD)	N/A
Muscular Dystrophy	N/A
Loss of muscle coordination	N/A
Rheumatoid Arthritis	N/A
Reiter's Disease	N/A
Club foot	N/A
Deafness before age of 60	N/A
Cataracts before age of 60	N/A
Blindness in both eyes before age of 60	N/A
Glaucoma	N/A
Macular Degeneration	N/A
Acne	N/A
Psoriasis	N/A
Albinism	N/A
More than 5 purple or coffee-colored spots on the skin-1.5 cm (1/2 inch) or larger	N/A
Drug abuse, misuse, or addiction	N/A
Cleft palate or cleft lip	N/A
Serious birth defects	N/A
Inguinal hernia	N/A
Premature degeneration of any organ system	N/A
The same cancer in more than one family member	N/A

Donor Medical History

Question	Response
List any operations: Age & reason:	N/A
Hospitalization other than surgery: Age & type of illness:	N/A
Have you ever had any broken bones? If yes, please give age and description:	N/A
Have you ever had any serious illnesses? If yes, please give age and description:	N/A
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:	N/A
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:	N/A
List all current medication or treatments (include vitamins, aspirin, antacids, laxatives, herbal, sports supplements, etc.) Include drug, frequency and duration taken, and reason:	N/A
Do you wear glasses or contact lenses? Are you near or far-sighted?	N/A
Usual weight?	N/A
Recent weight loss or gain? # of lbs and reason:	N/A
Allergies (medicines, food, pollens)? If yes, please list substance and reaction caused:	N/A
Have you been tested for HIV (AIDS)? If yes, when:	Yes - Negative, ongoing donor screening
Sexual orientation:	N/A
How many sexual partners do you currently have?	N/A
Have you ever had a tattoo? If yes, what year did you get the tattoo?	N/A
Have you ever had your ear(s) or body pierced? If yes, where and what year?	N/A

Family Medical History
See list of questions asked here

Your Mother

Question	Response	Comment/Age Affected
Current age or age at death	66
Health Problem	High blood pressure, controlled by diet and exercise	55
Living / Dead	Living

Your Father

Question	Response	Comment/Age Affected
Current age or age at death	68
Health Problem	Healthy
Living / Dead	Living

Brothers

Your Brother 1

Question	Response	Comment/Age Affected
Current age or age at death	32
Health Problem	Healthy
Living / Dead	Living

Daughters

Your Daughter 1

Question	Response	Comment/Age Affected
Current age or age at death	5
Health Problem	Healthy
Living / Dead	Living

Your Mother's Father

Question	Response	Comment/Age Affected
Current age or age at death	92
Health Problem	Kidney failure	90
Living / Dead	Dead

Your Mother's Mother

Question	Response	Comment/Age Affected
Current age or age at death	88
Health Problem	Heart attack, died in her sleep	88
Living / Dead	Dead

Your Mother's Brothers 1

Question	Response	Comment/Age Affected
Current age or age at death	52
Health Problem	Healthy
Living / Dead	Living

Your Mother's Brothers 2

Question	Response	Comment/Age Affected
Current age or age at death	48
Health Problem	Healthy
Living / Dead	Living

Your Mother's Brothers 3

Question	Response	Comment/Age Affected
Current age or age at death	42
Health Problem	Healthy
Living / Dead	Living

Your Father's Father

Question	Response	Comment/Age Affected
Current age or age at death	59
Health Problem	Cause of death: Machinery accident	59
Living / Dead	Dead

Your Father's Mother

Question	Response	Comment/Age Affected
Current age or age at death	82
Health Problem	Cancer	81
Living / Dead	Dead

Your Father's Sisters 1

Question	Response	Comment/Age Affected
Current age or age at death	70
Health Problem	Healthy
Living / Dead	Living

Your Father's Sisters 2

Question	Response	Comment/Age Affected
Current age or age at death	58
Health Problem	Healthy
Living / Dead	Living

Your Father's Brothers 1

Question	Response	Comment/Age Affected
Current age or age at death	67
Health Problem	High blood pressure (mild)	60
Living / Dead	Living

Your Father's Brothers 2

Question	Response	Comment/Age Affected
Current age or age at death	66
Health Problem	Healthy
Living / Dead	Living

Your Father's Brothers 3

Question	Response	Comment/Age Affected
Current age or age at death	64
Health Problem	Healthy
Living / Dead	Living

Your Father's Brothers 4

Question	Response	Comment/Age Affected
Current age or age at death	60
Health Problem	High blood pressure (mild)	60
Living / Dead	Living

Donor Number: 1886

Personal Behavior History

Sexual History

Donor Genetic History

Donor Medical History

Family Medical HistorySee list of questions asked here

Family Medical History
See list of questions asked here