Donor 5113 - Medical Profile

Personal Behavior History

Question	Response
Current alcohol use: If yes, oz./week and type of alcohol:	Rarely - 2 alcoholic drinks/month
Have you or any of your family members been diagnosed with alcoholism or drug addiction? If yes, relation and age affected:	Yes - Maternal grandfather, ages 30-45 (recovered with treatment)
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 the 147 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 - for mutations tested

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):	Yes - Non-carrier for mutations tested
Gaucher: If yes, result(s):	Yes - Non-carrier for mutations tested
Canavan: If yes, result(s):	Yes - Non-carrier for mutations tested
Fanconi Anemia Type C: If yes, result(s):	Yes - Non-carrier for mutations tested
Niemann-Pick Type A: If yes, result(s):	Yes - Non-carrier for mutations tested
Bloom Syndrome: If yes, result(s):	Yes - Non-carrier for mutations tested
Familial Dysautonomia: If yes, result(s):	Yes - Non-carrier for mutations tested
Mucolipidosis IV: If yes, result(s):	Yes - Non-carrier for mutations tested
Maple Syrup Urine Disease 1B: If yes, result(s):	Yes - Non-carrier for mutations tested
Usher Syndrome III & 1F: If yes, result(s):	Yes - Non-carrier for mutations tested
Glycogen Storage Disease 1A: If yes, result(s):	Yes - Non-carrier for mutations tested
ABCC8-Related Hyperinsulinism: If yes, result(s):	Yes - Non-carrier for mutations tested
BRCA1/BRCA2: If yes, result(s):	No
Lipoamide Dehydrogenase Deficiency: If yes, result(s):	Yes - Non-carrier for mutations tested

Ancestry

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

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 87 (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	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	Aunt/Uncle - Paternal aunt #2, ages 27 and 28 (due to multiple sclerosis, two later successful pregnancies)
Herpes simplex virus, genital	None
Migraines	Mother - age 42 (controlled with over-the-counter medication)
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	Self - ages 14-24 (controlled with over-the-counter cream); Mother, ages 15-35 (controlled with over-the-counter cream)
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	Grandparent - Maternal grandfather, ages 30-45 (recovered with treatment)
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	Grandparent - Maternal grandmother, Paternal grandmother (lung cancer)

Donor Medical History

Question	Response
List any operations: Age & reason:	Wisdom teeth extraction surgery at age 14; Reconstructive ankle surgery at age 32, sports injury
Hospitalization other than surgery: Age & type of illness:	N/A
Have you ever had any broken bones? If yes, please give age and description:	Yes - Broken left wrist at age 11 due to falling off father's motorcycle; Broken jaw at age 16, sports injury
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:	1 - 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:	Vitamin C, taken daily; Advil, taken as needed for minor headaches
List all current medication or treatments (include vitamins, aspirin, antacids, laxatives, herbal, sports supplements, etc.) Include drug, frequency and duration taken, and reason:	Vitamin C, taken daily
Do you wear glasses or contact lenses? Are you near or far-sighted?	No
Usual weight?	206
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?	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?	No

Family Medical History
See list of questions asked here

Your Mother

Question	Response	Comment/Age Affected
Current age or age at death	59
Health Problem	Ovarian cyst, treated with surgery	39
Health Problem	Migraines, controlled with over-the-counter medication	42
Living / Dead	Living

Your Father

Question	Response	Comment/Age Affected
Current age or age at death	61
Health Problem	High blood pressure, controlled with medication and diet modifications	55
Living / Dead	Living

Sisters

Your Sister 1

Question	Response	Comment/Age Affected
Current age or age at death	33
Health Problem	Depression, treated with therapy	15
	Obese, no treatment, following two pregnancies	27
	Ulcers, controlled with medication	30
Living / Dead	Living

Sons

Your Son 1

Question	Response	Comment/Age Affected
Current age or age at death	5
Health Problem	Healthy
Living / Dead	Living

Daughters

Your Daughter 1

Question	Response	Comment/Age Affected
Current age or age at death	2
Health Problem	Healthy
Living / Dead	Living

Your Mother's Father

Question	Response	Comment/Age Affected
Current age or age at death	87
Health Problem	Alcoholic, recovered with treatment	30
	Heart attack, no treatment	87
	Cause of death: Heart attack	87
Living / Dead	Dead

Your Mother's Mother

Question	Response	Comment/Age Affected
Current age or age at death	72
Health Problem	Lung cancer (smoker), attempted treatment with chemotherapy and radiation	72
Health Problem	Cause of death: Lung cancer	72
Living / Dead	Dead

Your Mother's Brothers 1

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

Your Father's Father

Question	Response	Comment/Age Affected
Current age or age at death	38
Health Problem	Healthy
	Severe trauma due to plane crash, no treatment	38
	Cause of death: Severe trauma	38
Living / Dead	Dead

Your Father's Mother

Question	Response	Comment/Age Affected
Current age or age at death	67
Health Problem	Lung cancer (smoker), no treatment	65
Health Problem	Cause of death: Lung cancer	67
Living / Dead	Dead

Your Father's Sisters 1

Question	Response	Comment/Age Affected
Current age or age at death	59
Health Problem	Healthy
Living / Dead	Living

Your Father's Sisters 2

Question	Response	Comment/Age Affected
Current age or age at death	57
Health Problem	Multiple sclerosis, mildly affected, controlled with medication	26
	Miscarriage, due to MS, no treatment	27
	Miscarriage, due to MS, no treatment, two successful pregnancies following	28
Living / Dead	Living

Your Father's Brothers 1

Question	Response	Comment/Age Affected
Current age or age at death	55
Health Problem	Healthy
Living / Dead	Living

Donor Number: 5113

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