Personal Behavior History
Question | Response |
Current alcohol use: If yes, oz./week and type of alcohol: | Daily - 144 oz. beer/week |
Have you or any of your family members been diagnosed with alcoholism or drug addiction? If yes, relation and age affected: | Yes - Maternal grandmother, age 30 |
Tobacco use: Do you smoke? If yes, #/day and for how long: | No |
If you did smoke but quit, when did you last smoke? | 2002 |
For how many years? | 4 - (only socially, ~5-7 cigarettes/week) |
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 | None |
Congenital heart disease | None |
Hemophilia/bleeding problem | None |
Emphysema | Grandparent - Maternal grandmother, age 72 (smoker, treated with hospitalization), cause of death |
Cystic Fibrosis | None |
Alpha-1 Antitrypsin Deficiency | None |
Pyloric stenosis | None |
Colon cancer | None |
Inflammatory bowel disease | None |
Irritable Bowel Syndrome | Sibling - Sister, age 26 (treats with medication and diet) |
Diabetes mellitus requiring insulin therapy | None |
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 | None |
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 | None |
Reiter's Disease | None |
Club foot | None |
Deafness before age of 60 | None |
Cataracts before age of 60 | None |
Blindness in both eyes before age of 60 | None |
Glaucoma | None |
Macular Degeneration | None |
Acne | None |
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: | Tonsillectomy at age 17 (recommended by doctor) |
Hospitalization other than surgery: Age & type of illness: | None |
Have you ever had any broken bones? If yes, please give age and description: | Yes - Collar bone at age 12 (bicycle accident); Tibia at age 16 (ski 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: | 5 - Cold, Flu |
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: | Creatine for 2-3 weeks after intense workouts; Multivitamin 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 daily for general health |
Do you wear glasses or contact lenses? Are you near or far-sighted? | Yes - Far-sighted |
Usual weight? | 185 |
Recent weight loss or gain? # of lbs and reason: | No |
Allergies (medicines, food, pollens)? If yes, please list substance and reaction caused: | Yes - Erythromycin: Causes rash |
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 - 2010 |
Have you ever had your ear(s) or body pierced? If yes, where and what year? | Yes - Ears (now closed), 1998 |
Family Medical HistorySee list of questions asked here
Your Mother
Question | Response | Comment/Age Affected |
Current age or age at death | 62 | |
Health Problem | Interstitial cystitis (treated with medication/diet) | 50 |
Living / Dead | Living |
Your Father
Question | Response | Comment/Age Affected |
Current age or age at death | 62 | |
Health Problem | High blood pressure (treated with medication) | 54 |
Living / Dead | Living |
Sisters
Your Sister 1
Question | Response | Comment/Age Affected |
Current age or age at death | 31 | |
Health Problem | Irritable Bowel Syndrome (treats with medication and diet) | 26 |
Living / Dead | Living |
Your Mother's Father
Question | Response | Comment/Age Affected |
Current age or age at death | 78 | |
Health Problem | Pneumonia (treated with hospitalization) | 78 |
Cause of death: Pneumonia | 78 | |
Living / Dead | Dead |
Your Mother's Mother
Question | Response | Comment/Age Affected |
Current age or age at death | 72 | |
Health Problem | Emphysema (long-term smoker, treated with hospitalization) | 72 |
Cause of death: Emphysema | 72 | |
Living / Dead | Dead |
Your Mother's Sisters 1
Question | Response | Comment/Age Affected |
Current age or age at death | 57 | |
Health Problem | Healthy | |
Living / Dead | Living |
Your Mother's Brothers 1
Question | Response | Comment/Age Affected |
Current age or age at death | 53 | |
Health Problem | Healthy | |
Living / Dead | Living |
Your Father's Father
Question | Response | Comment/Age Affected |
Current age or age at death | 87 | |
Health Problem | Chronic Obstructive Pulmonary Disease (COPD, long-term smoker, treated with oxygen) | 85 |
Cause of death: COPD complications | 87 | |
Living / Dead | Dead |
Your Father's Mother
Question | Response | Comment/Age Affected |
Current age or age at death | 89 | |
Health Problem | Healthy | |
Living / Dead | Living |
Your Father's Brothers 1
Question | Response | Comment/Age Affected |
Current age or age at death | 66 | |
Health Problem | Healthy | |
Living / Dead | Living |
Your Father's Brothers 2
Question | Response | Comment/Age Affected |
Current age or age at death | 58 | |
Health Problem | Healthy | |
Red/Green colorblind | ||
Living / Dead | Living |