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Personal Behavior History

Question Response
Current alcohol use:
If yes, oz./week and type of alcohol:
Rarely - 12-24 oz. beer or 6-12 oz. wine/month
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:
Yes - Mildly lactose intolerant; Mildly allergic to eggs, but can consume small amounts

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:
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?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
Heart attackNone
Congenital heart diseaseNone
Hemophilia/bleeding problemNone
EmphysemaNone
Cystic FibrosisNone
Alpha-1 Antitrypsin DeficiencyNone
Pyloric stenosisNone
Colon cancerGrandparent - Paternal grandfather, age 98 (no treatment received, cause of death)
Inflammatory bowel diseaseNone
Irritable Bowel SyndromeNone
Diabetes mellitus requiring insulin therapyNone
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)Self - three years ago, (situational, caused by stress of medical school, treated with medication, no longer take it)
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 19
Hospitalization other than surgery:
Age & type of illness:
Chlorine gas exposure, age 10 (downwind of industrial accident, treated with oxygen)
Have you ever had any broken bones?
If yes, please give age and description:
No
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 and minerals taken daily; Allegra, Omnaris, taken as needed, for hay fever allergies; Tylenol taken a few times a month for minor aches and pains
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 minerals taken daily
Do you wear glasses or contact lenses?
Are you near or far-sighted?
Yes - Near-sighted
Usual weight?169
Recent weight loss or gain?
# of lbs and reason:
No
Allergies (medicines, food, pollens)?
If yes, please list substance and reaction caused:
Yes - Pollen: Causes hay fever symptoms; Eggs: Cause GI upset; Cats: Cause itchy eyes, sometimes nasal congestion
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?N/A
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 40
Health Problem Lung cancer (non-smoker, but exposed to second-hand smoke), age of onset unknown, chemotherapy 
Cause of death: Lung cancer40
Living / DeadDead
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 36
Health Problem Healthy 
Living / DeadLiving
Question Response Comment/Age Affected
Current age or age at death 70
Health Problem Stroke, treated with medication65
Cause of death: Complications from stroke70
Living / DeadDead
Question Response Comment/Age Affected
Current age or age at death 50
Health Problem Brain abscess, treatment, if any, unknown50
Cause of death: Brain abscess50
Living / DeadDead
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 72
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 79
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 98
Health Problem Colon cancer, no treatment received98
Cause of death: Colon cancer98
Living / DeadDead
Question Response Comment/Age Affected
Current age or age at death 88
Health Problem Osteoarthritis (mild), treated with over-the-counter medication70
Hypertension, treated with medication80
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 61
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 1
Health Problem Dysentery, no details available1
Cause of death: Dysentery1
Living / DeadDead