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Personal Behavior History

Question Response
Current alcohol use:
If yes, oz./week and type of alcohol:
Never
Have you or any of your family members been diagnosed with alcoholism or drug addiction?
If yes, relation and age affected:
No
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?0
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

Question Response
A partner whose sexual background you are unsure of in the past 12 months?No
Another man anal or oral, even once, since 1977?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 for the 99 mutations tested
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 enzyme analysis
Question Response
Are you of Jewish ancestry?
If yes, please note: Ashkenazi, Sephardi, or Other
No
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
Question Response
Are you of African ancestry?No
If yes, have you been tested as a carrier of sickle cell anemia?Yes - Standard donor screening
If yes, result:Non Carrier
Are you of Mediterranean, Greek or Italian ancestry?Yes
If yes, have you been tested as a carrier of beta thalassemia?Yes - Standard donor screening
If yes, result:Non Carrier
Heart attackGrandparent - Paternal grandmother, age 87 (no treatment, cause of death)
Congenital heart diseaseNone
Hemophilia/bleeding problemNone
EmphysemaNone
Cystic FibrosisNone
Alpha-1 Antitrypsin DeficiencyNone
Pyloric stenosisNone
Colon cancerNone
Inflammatory bowel diseaseNone
Irritable Bowel SyndromeNone
Diabetes mellitus requiring insulin therapyNone
Diabetes mellitus not requiring insulin therapyAunt/Uncle - Maternal aunt #2, age 55 (controlled with diet management)
PKU or inherited metabolism disorderNone
Progressive kidney diseaseNone
Polycystic kidney diseaseNone
Miscarriages or stillbornNone
Herpes simplex virus, genitalNone
MigrainesNone
Mental retardationNone
Senility or mental deterioration before age 60None
Epilepsy/seizuresNone
Neural tube defects - open spine or hydrocephalus/water on the brainNone
Huntington's diseaseNone
Tuberous sclerosisNone
NeurofibromatosisNone
Parkinson's diseaseNone
Down SyndromeNone
AutismNone
Autism Spectrum DisorderNone
Pervasive Developmental Delay (PDD)None
Asperger's SyndromeNone
SchizophreniaNone
Bipolar (manic depressive psychosis)None
Attention Deficit Disorder (ADD)None
Attention Deficit Hyperactivity Disorder (ADHD)None
Muscular DystrophyNone
Loss of muscle coordinationNone
Rheumatoid ArthritisNone
Reiter's DiseaseNone
Club footNone
Deafness before age of 60None
Cataracts before age of 60None
Blindness in both eyes before age of 60None
GlaucomaNone
Macular DegenerationNone
AcneNone
PsoriasisNone
AlbinismNone
More than 5 purple or coffee-colored spots on the skin-1.5 cm (1/2 inch) or largerNone
Drug abuse, misuse, or addictionNone
Cleft palate or cleft lipNone
Serious birth defectsNone
Inguinal herniaNone
Premature degeneration of any organ systemNone
The same cancer in more than one family memberNone

Donor Medical History

Question Response
List any operations:
Age & reason:
Wisdom teeth extraction surgery at age 18; Shoulder surgery at age 30 due to torn rotator cuff
Hospitalization other than surgery:
Age & type of illness:
Pneumonia at age 28
Have you ever had any broken bones?
If yes, please give age and description:
Yes - Broken leg at age 16 due to skiing 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:
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:Multivitamin taken daily for general health
List all current medication or treatments (include vitamins, aspirin, antacids, laxatives, herbal, sports supplements, etc.) Include drug, frequency and duration taken, and reason:Multivitamin taken daily for general health
Do you wear glasses or contact lenses?
Are you near or far-sighted?
No
Usual weight?171
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
Sexual orientation:Heterosexual
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 - 2003
Have you ever had your ear(s) or body pierced?
If yes, where and what year?
Yes - Both ears, 1997

Family Medical History
See list of questions asked here

Question Response Comment/Age Affected
Current age or age at death 61
Health Problem Healthy 
Living / DeadLiving
Question Response Comment/Age Affected
Current age or age at death 62
Health Problem Gout, managed with medication45
Living / DeadLiving
Question Response Comment/Age Affected
Current age or age at death 34
Health Problem Healthy 
Living / DeadLiving
Question Response Comment/Age Affected
Current age or age at death 31
Health Problem Healthy 
Living / DeadLiving
Question Response Comment/Age Affected
Current age or age at death 36
Health Problem Healthy 
Living / DeadLiving
Question Response Comment/Age Affected
Current age or age at death 96
Health Problem Organ failure, no treatment96
Cause of death: Natural causes, organ failure96
Living / DeadDead
Question Response Comment/Age Affected
Current age or age at death 98
Health Problem Organ failure, no treatment98
Cause of death: Natural causes, organ failure98
Living / DeadDead
Question Response Comment/Age Affected
Current age or age at death 60
Health Problem Healthy 
Living / DeadLiving
Question Response Comment/Age Affected
Current age or age at death 58
Health Problem Diabetes mellitus not requiring insulin therapy, controlled with diet management55
Living / DeadLiving
Question Response Comment/Age Affected
Current age or age at death 66
Health Problem Healthy 
Living / DeadLiving
Question Response Comment/Age Affected
Current age or age at death 64
Health Problem Healthy 
Living / DeadLiving
Question Response Comment/Age Affected
Current age or age at death 57
Health Problem Healthy 
Living / DeadLiving
Question Response Comment/Age Affected
Current age or age at death 88
Health Problem Stroke, no treatment88
Cause of death: Stroke88
Living / DeadDead
Question Response Comment/Age Affected
Current age or age at death 87
Health Problem Heart attack, no treatment87
Cause of death: Heart attack87
Living / DeadDead
Question Response Comment/Age Affected
Current age or age at death 66
Health Problem Fibromyalgia, treated with medication58
Living / DeadLiving
Question Response Comment/Age Affected
Current age or age at death 64
Health Problem Healthy 
Living / DeadLiving
Question Response Comment/Age Affected
Current age or age at death 65
Health Problem Healthy 
Living / DeadLiving
Question Response Comment/Age Affected
Current age or age at death 58
Health Problem Healthy 
Living / DeadLiving