Personal Behavior History

Question Response
Current alcohol use:
If yes, oz./week and type of alcohol:
Daily - 8 oz. of liquor/week
Have you or any of your family members been diagnosed with alcoholism or drug addiction?
If yes, relation and age affected:
Yes - Paternal uncle #2, age 35 (undergoing recovery)
Tobacco use: Do you smoke?
If yes, #/day and for how long:
No
If you did smoke but quit, when did you last smoke?2006
For how many years?1
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 - Standard donor screening
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 - Maternal grandmother, age 68 (no treatment); Maternal grandfather, age 79 (no treatment)
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 therapyGrandparent - Maternal grandmother, age 58 (controlled with diet modification)
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
AutismAunt/Uncle - Paternal uncle #1, age 2 (no treatment)
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 addictionAunt/Uncle - Paternal uncle #2, alcoholism, age 35 (undergoing recovery)
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
Hospitalization other than surgery:
Age & type of illness:
Hospitalization for minor injuries following car accident at age 22
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:
2 - Food poisoning
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 health maintenance; Whey protein taken 3-4 times a week for muscle gain and health maintenance; Aspirin taken as needed for occasional minor 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 taken daily for health maintenance; Whey protein taken 3-4 times a week for muscle gain and health maintenance
Do you wear glasses or contact lenses?
Are you near or far-sighted?
Yes - Near-sighted
Usual weight?172
Recent weight loss or gain?
# of lbs and reason:
No
Allergies (medicines, food, pollens)?
If yes, please list substance and reaction caused:
Yes - Pollens: Cause runny nose, itchy eyes
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, 2006, 2008, 2011, 2013
Have you ever had your ear(s) or body pierced?
If yes, where and what year?
Yes - Left earlobe, 2005

Family Medical History
See list of questions asked here

Question Response Comment/Age Affected
Current age or age at death 50
Health Problem Healthy 
Living / DeadLiving
Question Response Comment/Age Affected
Current age or age at death 53
Health Problem Healthy 
Living / DeadLiving
Question Response Comment/Age Affected
Current age or age at death 23(Paternal half brother)
Health Problem Healthy 
Living / DeadLiving
Question Response Comment/Age Affected
Current age or age at death 12(Paternal half brother)
Health Problem Healthy 
Living / DeadLiving
Question Response Comment/Age Affected
Current age or age at death 11(Paternal half sister)
Health Problem Brain damage due to lack of oxygen at birth 
Living / DeadLiving
Question Response Comment/Age Affected
Current age or age at death 79
Health Problem Heart attack, no treatment79
Living / DeadLiving
Question Response Comment/Age Affected
Current age or age at death 68
Health Problem Diabetes mellitus not requiring insulin therapy, controlled with diet modifications58
Heart attack, no treatment68
Stroke, no treatment68
Cause of death: Stroke68
Living / DeadDead
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 76
Health Problem Osteoarthritis, controlled with over-the-counter medication70
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 61
Health Problem Healthy 
Living / DeadLiving
Question Response Comment/Age Affected
Current age or age at death 58
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 53
Health Problem Healthy 
Living / DeadLiving
Question Response Comment/Age Affected
Current age or age at death 50
Health Problem Healthy 
Living / DeadLiving
Question Response Comment/Age Affected
Current age or age at death 48
Health Problem Healthy 
Living / DeadLiving
Question Response Comment/Age Affected
Current age or age at death 49
Health Problem Autism, no treatment2
Heart failure, no treatment49
Cause of death: Heart failure49
Living / DeadDead
Question Response Comment/Age Affected
Current age or age at death 63
Health Problem Obesity, no treatment30
Alcoholism, currently recovering35
High blood pressure, controlled with diet modification51
High cholesterol, controlled with medication51
Stroke, no treatment57
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 56
Health Problem Healthy 
Living / DeadLiving
Question Response Comment/Age Affected
Current age or age at death 49
Health Problem Healthy 
Living / DeadLiving
Question Response Comment/Age Affected
Current age or age at death 46
Health Problem Healthy 
Living / DeadLiving