Donor 4069 - Medical Profile

Personal Behavior History

Question	Response
Current alcohol use: If yes, oz./week and type of alcohol:	Frequently - 24 oz. beer or wine/week
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

Have you ever had sex with:

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 at least 97 mutations
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 - Standard donor screening

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):	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?	Yes - Standard donor screening
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 grandfather, age 64, no treatment (cause of death); Paternal grandmother, age 65, no treatment (cause of death)
Congenital heart disease	None
Hemophilia/bleeding problem	None
Emphysema	None
Cystic Fibrosis	None
Alpha-1 Antitrypsin Deficiency	None
Pyloric stenosis	None
Colon cancer	None
Inflammatory bowel disease	None
Irritable Bowel Syndrome	None
Diabetes mellitus requiring insulin therapy	Grandparent - Paternal grandmother, age 48
Diabetes mellitus not requiring insulin therapy	None
PKU or inherited metabolism disorder	None
Progressive kidney disease	None
Polycystic kidney disease	None
Miscarriages or stillborn	None
Herpes simplex virus, genital	None
Migraines	None
Mental retardation	None
Senility or mental deterioration before age 60	None
Epilepsy/seizures	None
Neural tube defects - open spine or hydrocephalus/water on the brain	None
Huntington's disease	None
Tuberous sclerosis	None
Neurofibromatosis	None
Parkinson's disease	Grandparent - Maternal grandmother, age 84, no treatment
Down Syndrome	None
Autism	None
Autism Spectrum Disorder	None
Pervasive Developmental Delay (PDD)	None
Asperger's Syndrome	None
Schizophrenia	None
Bipolar (manic depressive psychosis)	None
Attention Deficit Disorder (ADD)	None
Attention Deficit Hyperactivity Disorder (ADHD)	None
Muscular Dystrophy	None
Loss of muscle coordination	None
Rheumatoid Arthritis	Grandparent - Paternal grandfather, age 80, treated with medication
Reiter's Disease	None
Club foot	None
Deafness before age of 60	None
Cataracts before age of 60	Father - age 59, treated with surgery
Blindness in both eyes before age of 60	None
Glaucoma	None
Macular Degeneration	None
Acne	Self - mild, in high school, no treatment
Psoriasis	None
Albinism	None
More than 5 purple or coffee-colored spots on the skin-1.5 cm (1/2 inch) or larger	None
Drug abuse, misuse, or addiction	None
Cleft palate or cleft lip	None
Serious birth defects	None
Inguinal hernia	None
Premature degeneration of any organ system	None
The same cancer in more than one family member	None

Donor Medical History

Question	Response
List any operations: Age & reason:	Wisdom teeth removal at age 18, impacted
Hospitalization other than surgery: Age & type of illness:	None
Have you ever had any broken bones? If yes, please give age and description:	Yes - Two broken fingers, age 7, playground 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:	Ibuprofen, occasionally, for relief from athletic-induced pain
List all current medication or treatments (include vitamins, aspirin, antacids, laxatives, herbal, sports supplements, etc.) Include drug, frequency and duration taken, and reason:	Multivitamin and Omega 3 fatty acid supplementation daily
Do you wear glasses or contact lenses? Are you near or far-sighted?	No - (Near-sighted before laser surgery)
Usual weight?	155
Recent weight loss or gain? # of lbs and reason:	No
Allergies (medicines, food, pollens)? If yes, please list substance and reaction caused:	Yes - Cats and dogs are all that bother me anymore, runny nose and scratchy throat are only reactions
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?	No
Have you ever had your ear(s) or body pierced? If yes, where and what year?	Yes - Ear, on three occasions as an adult

Family Medical History
See list of questions asked here

Your Mother

Question	Response	Comment/Age Affected
Current age or age at death	60
Health Problem	Healthy
Living / Dead	Living

Your Father

Question	Response	Comment/Age Affected
Current age or age at death	60
Health Problem	Melanoma, treated with immunotherapy after cancer was resected, currently healthy with no disease	54
Health Problem	Cataracts, treated with surgery	59
Living / Dead	Living

Brothers

Your Brother 1

Question	Response	Comment/Age Affected
Current age or age at death	23
Health Problem	Healthy
Living / Dead	Living

Your Mother's Father

Question	Response	Comment/Age Affected
Current age or age at death	64
Health Problem	Heart attack, heavy smoker, no treatment	64
Health Problem	Cause of death: Heart attack	64
Living / Dead	Dead

Your Mother's Mother

Question	Response	Comment/Age Affected
Current age or age at death	89
Health Problem	Parkinson's Disease, no treatment	84
Health Problem	Cause of death: Increasing frailty, numerous broken bones and long/involved treatment regimens	89
Living / Dead	Dead

Your Mother's Sisters 1

Question	Response	Comment/Age Affected
Current age or age at death	62
Health Problem	Healthy
Living / Dead	Living

Your Mother's Sisters 2

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

Your Mother's Brothers 1

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

Your Mother's Brothers 2

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

Your Mother's Brothers 3

Question	Response	Comment/Age Affected
Current age or age at death	53
Health Problem	Healthy
Living / Dead	Living

Your Mother's Brothers 4

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

Your Father's Father

Question	Response	Comment/Age Affected
Current age or age at death	84
Health Problem	Rheumatoid arthritis, treated with medication	80
	Brain tumor, benign, inoperable, treatment minimal	82
	Thyroid cancer, treated with surgery, but too old for chemotherapy	84
	Cause of death: Thyroid cancer and brain tumor	84
Living / Dead	Dead

Your Father's Mother

Question	Response	Comment/Age Affected
Current age or age at death	65
Health Problem	Obesity, no treatment	45
	Diabetes, treated with insulin	48
	Cause of death: Heart attack, no treatment	65
Living / Dead	Dead

Your Father's Sisters 1

Question	Response	Comment/Age Affected
Current age or age at death	53
Health Problem	Healthy
Living / Dead	Living

Donor Number: 4069

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