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:
Yes - 10/day for 10 years
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 variant: 46,XY,inv(9)(p11q13) (common polymorphism without significance)
Spinal Muscular Atrophy (SMA)?
If yes, the result:
Non Carrier - Standard donor screening
Tay Sachs?
If yes, the result:
Unknown - Donor was not tested
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?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
Heart attackGrandparent - Paternal grandfather, age 55 (no treatment, cause of death); Maternal grandfather, age 53 (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 therapyAunt/Uncle - Paternal uncle #1, age 70 (cause of death)
Diabetes mellitus not requiring insulin therapyNone
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 herniaSelf - age 6 months (treated with surgery)
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:
Surgery to repair inguinal hernia at 6 months of age; Wisdom teeth extraction surgery at age 24
Hospitalization other than surgery:
Age & type of illness:
None
Have you ever had any broken bones?
If yes, please give age and description:
Yes - Broken finger at age 15 due to sports 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:None
List all current medication or treatments (include vitamins, aspirin, antacids, laxatives, herbal, sports supplements, etc.) Include drug, frequency and duration taken, and reason:None
Do you wear glasses or contact lenses?
Are you near or far-sighted?
No
Usual weight?199
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?0
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?
No

Family Medical History
See list of questions asked here

Question Response Comment/Age Affected
Current age or age at death 61
Health Problem Asthma, controlled with inhaler55
Living / DeadLiving
Question Response Comment/Age Affected
Current age or age at death 74
Health Problem Healthy 
Living / DeadLiving
Question Response Comment/Age Affected
Current age or age at death 35
Health Problem Lactose intolerance, outgrew symptoms at age 186
Living / DeadLiving
Question Response Comment/Age Affected
Current age or age at death 26
Health Problem Healthy 
Living / DeadLiving
Question Response Comment/Age Affected
Current age or age at death 42Paternal half sister
Health Problem Healthy 
Living / DeadLiving
Question Response Comment/Age Affected
Current age or age at death 7
Health Problem Healthy 
Living / DeadLiving
Question Response Comment/Age Affected
Current age or age at death 53
Health Problem Heart attack, due to smoking, no treatment53
Cause of death: Heart attack53
Living / DeadDead
Question Response Comment/Age Affected
Current age or age at death 93
Health Problem Cataracts, both eyes, no treatment75
Heart failure, no treatment93
Cause of death: Heart failure93
Living / DeadDead
Question Response Comment/Age Affected
Current age or age at death 68
Health Problem Healthy 
Living / DeadLiving
Question Response Comment/Age Affected
Current age or age at death 67
Health Problem Healthy 
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 65
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 62
Health Problem Healthy 
Living / DeadLiving
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 60
Health Problem Healthy 
Living / DeadLiving
Question Response Comment/Age Affected
Current age or age at death 59
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 56
Health Problem Healthy 
Living / DeadLiving
Question Response Comment/Age Affected
Current age or age at death 55
Health Problem Healthy 
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 55
Health Problem Heart attack, no treatment55
Cause of death: Heart attack55
Living / DeadDead
Question Response Comment/Age Affected
Current age or age at death 90
Health Problem Broken hip, treated in hospital90
Cause of death: Complications from broken hip90
Living / DeadDead
Question Response Comment/Age Affected
Current age or age at death 71
Health Problem Breast cancer, attempted treatment with surgery68
Cause of death: Breast cancer71
Living / DeadDead
Question Response Comment/Age Affected
Current age or age at death 70
Health Problem Respiratory failure, no treatment70
Cause of death: Respiratory failure70
Living / DeadDead
Question Response Comment/Age Affected
Current age or age at death 64Identical twin
Health Problem Healthy 
Living / DeadLiving
Question Response Comment/Age Affected
Current age or age at death 64Identical twin
Health Problem Healthy 
Living / DeadLiving
Question Response Comment/Age Affected
Current age or age at death 76
Health Problem Diabetes mellitus requiring insulin therapy70
Cause of death: Complications from diabetes76
Living / DeadDead
Question Response Comment/Age Affected
Current age or age at death 75
Health Problem Heart failure, no treatment75
Cause of death: Heart failure75
Living / DeadDead
Question Response Comment/Age Affected
Current age or age at death 74
Health Problem Heart failure, no treatment74
Cause of death: Heart failure74
Living / DeadDead
Question Response Comment/Age Affected
Current age or age at death 70
Health Problem Healthy 
Living / DeadLiving