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:
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?No
Is your diet well balanced?
If no, explain:
Yes
Are you a vegetarian?Yes
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 149 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
Question Response
Are you of Jewish ancestry?
If yes, please note: Ashkenazi, Sephardi, or Other
No
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
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 attackGrandparent - Maternal grandfather, age 78, cause of death; Paternal grandfather, age 45, cause of death; Aunt/Uncle - Paternal uncle #2, age 68, 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 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)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 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:
None
Hospitalization other than surgery:
Age & type of illness:
N/A
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:Omerazole, taken for six weeks for heartburn
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?
Yes - Near-sighted
Usual weight?167
Recent weight loss or gain?
# of lbs and reason:
No
Allergies (medicines, food, pollens)?
If yes, please list substance and reaction caused:
Yes - Cedar and oak pollen: Causes sneezing, runny nose
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

Question Response Comment/Age Affected
Current age or age at death 58
Health Problem High blood pressure, controlled with medication50
Living / DeadLiving
Question Response Comment/Age Affected
Current age or age at death 64
Health Problem High blood pressure, controlled with medication58
Living / DeadLiving
Question Response Comment/Age Affected
Current age or age at death 40
Health Problem Healthy 
Living / DeadLiving
Question Response Comment/Age Affected
Current age or age at death 34
Health Problem Healthy 
Living / DeadLiving
Question Response Comment/Age Affected
Current age or age at death 35
Health Problem Healthy 
Living / DeadLiving
Question Response Comment/Age Affected
Current age or age at death 78
Health Problem Heart attack, fatal, no treatment78
Cause of death: Heart attack78
Living / DeadDead
Question Response Comment/Age Affected
Current age or age at death 70
Health Problem Leukemia, treated with radiation55
Cause of death: Complications of leukemia70
Living / DeadDead
Question Response Comment/Age Affected
Current age or age at death 50
Health Problem High blood pressure, controlled with medication40
Living / DeadLiving
Question Response Comment/Age Affected
Current age or age at death 57
Health Problem High cholesterol, controlled with medication40
Living / DeadLiving
Question Response Comment/Age Affected
Current age or age at death 48
Health Problem Unknown (estranged from family) 
Cause of death: Unknown48
Living / DeadDead
Question Response Comment/Age Affected
Current age or age at death 45
Health Problem Heart attack, fatal, no treatment45
Cause of death: Heart attack45
Living / DeadDead
Question Response Comment/Age Affected
Current age or age at death 70
Health Problem Healthy 
Cause of death: Heart failure70
Living / DeadDead
Question Response Comment/Age Affected
Current age or age at death 70
Health Problem Healthy 
Cause of death: Heart failure70
Living / DeadDead
Question Response Comment/Age Affected
Current age or age at death 72
Health Problem High blood pressure, controlled with medication50
Living / DeadLiving
Question Response Comment/Age Affected
Current age or age at death 66
Health Problem High blood pressure, controlled with medication45
Living / DeadLiving
Question Response Comment/Age Affected
Current age or age at death 14
Health Problem Healthy 
Cause of death: Accident14
Living / DeadDead
Question Response Comment/Age Affected
Current age or age at death 68
Health Problem Heart attack, fatal, no treatment68
Cause of death: Heart attack68
Living / DeadDead
Question Response Comment/Age Affected
Current age or age at death 55
Health Problem High blood pressure, controlled with medication45
Living / DeadLiving