Personal Behavior History

Question Response
Current alcohol use:
If yes, oz./week and type of alcohol:
Frequently - 32 oz. beer/week
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 - 1 cigarette/month, 2 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 by gene sequencing
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 - by gene sequencing
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 by gene sequencing
Gaucher:
If yes, result(s):
Yes - Non-carrier for mutations tested
Canavan:
If yes, result(s):
Yes - Non-carrier by gene sequencing
Fanconi Anemia Type C:
If yes, result(s):
Yes - Non-carrier by gene sequencing
Niemann-Pick Type A:
If yes, result(s):
Yes - Non-carrier by gene sequencing
Bloom Syndrome:
If yes, result(s):
Yes - Non-carrier by gene sequencing
Familial Dysautonomia:
If yes, result(s):
Yes - Non-carrier by gene sequencing
Mucolipidosis IV:
If yes, result(s):
Yes - Non-carrier by gene sequencing
Maple Syrup Urine Disease 1B:
If yes, result(s):
Yes - Non-carrier by gene sequencing
Usher Syndrome III & 1F:
If yes, result(s):
Yes - Non-carrier by gene sequencing
Glycogen Storage Disease 1A:
If yes, result(s):
Yes - Non-carrier by gene sequencing
ABCC8-Related Hyperinsulinism:
If yes, result(s):
Yes - Non-carrier by gene sequencing
BRCA1/BRCA2:
If yes, result(s):
No
Lipoamide Dehydrogenase Deficiency:
If yes, result(s):
Yes - Non-carrier by gene sequencing
Question Response
Are you of African ancestry?No
If yes, have you been tested as a carrier of sickle cell anemia?Yes
If yes, result:Non Carrier - by gene sequencing
Are you of Mediterranean, Greek or Italian ancestry?No
If yes, have you been tested as a carrier of beta thalassemia?Yes
If yes, result:Non Carrier - by gene sequencing
Heart attackAunt/Uncle - Maternal uncle #1, age 61, cause of death; Maternal uncle #2, age 58, 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 therapyGrandparent - Paternal grandfather, age 65; Paternal grandmother, age 49
Diabetes mellitus not requiring insulin therapyMother - age 53
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:
Leg surgery at age 6, both legs broken in a car accident
Hospitalization other than surgery:
Age & type of illness:
No
Have you ever had any broken bones?
If yes, please give age and description:
Yes - Both legs, age 6
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:Fish oil, taken daily; Glucosamine, taken three times per week; Vitamin D, taken twice per week
List all current medication or treatments (include vitamins, aspirin, antacids, laxatives, herbal, sports supplements, etc.) Include drug, frequency and duration taken, and reason:Fish oil, taken daily; Glucosamine, taken three times per week; Vitamin D, taken twice per week
Do you wear glasses or contact lenses?
Are you near or far-sighted?
Yes - Near-sighted
Usual weight?240
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?N/A
Have you ever had a tattoo?
If yes, what year did you get the tattoo?
Yes - 2015
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 60
Health Problem Type II Diabetes not requiring insulin therapy, treated with medication53
Living / DeadLiving
Question Response Comment/Age Affected
Current age or age at death 63
Health Problem Healthy 
Living / DeadLiving
Question Response Comment/Age Affected
Current age or age at death 31
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 65
Health Problem Cancer, unknown type, no treatment65
Cause of death: Cancer65
Living / DeadDead
Question Response Comment/Age Affected
Current age or age at death 55
Health Problem Cancer, unknown type, no treatment55
Cause of death: Cancer55
Living / DeadDead
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 63
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 61
Health Problem Heart attack, fatal, no treatment61
Cause of death: Heart attack61
Living / DeadDead
Question Response Comment/Age Affected
Current age or age at death 58
Health Problem Heart attack, fatal, no treatment58
Cause of death: Heart attack58
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 85
Health Problem Type II Diabetes requiring insulin therapy65
Living / DeadLiving
Question Response Comment/Age Affected
Current age or age at death 83
Health Problem Type II Diabetes requiring insulin therapy49
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 51
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 54
Health Problem Healthy 
Living / DeadLiving