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? | 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 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 |
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 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 |
Ancestry
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 |
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 55, 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 | None |
Herpes simplex virus, genital | None |
Migraines | None |
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 | Grandparent - Paternal grandfather, age 75 |
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 | Grandparent - Maternal grandmother, age 60 |
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 17-21, treated with over-the-counter medication |
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 | None |
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 | None |
Donor Medical History
Question | Response |
List any operations: Age & reason: | None |
Hospitalization other than surgery: Age & type of illness: | Yes - Broken clavicle, age 16 |
Have you ever had any broken bones? If yes, please give age and description: | Yes - Sternum fracture, age 12; Clavicle, age 16; Foot, age 19 (all sports injuries) |
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: | None |
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 - Far-sighted |
Usual weight? | 170 |
Recent weight loss or gain? # of lbs and reason: | No |
Allergies (medicines, food, pollens)? If yes, please list substance and reaction caused: | Yes - Penicillin: Causes rash |
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? | 0 |
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 HistorySee list of questions asked here
Your Mother
Question | Response | Comment/Age Affected |
Current age or age at death | 45 | |
Health Problem | Hypoglycemia, controlled with diet | 30 |
Living / Dead | Living |
Your Father
Question | Response | Comment/Age Affected |
Current age or age at death | 45 | |
Health Problem | Healthy | |
Living / Dead | Living |
Sisters
Your Sister 1
Question | Response | Comment/Age Affected |
Current age or age at death | 11 | Paternal half sister |
Health Problem | Healthy | |
Living / Dead | Living |
Your Sister 2
Question | Response | Comment/Age Affected |
Current age or age at death | 10 | Paternal half sister |
Health Problem | Healthy | |
Living / Dead | Living |
Your Sister 3
Question | Response | Comment/Age Affected |
Current age or age at death | 9 | Maternal half sister |
Health Problem | Healthy | |
Living / Dead | Living |
Your Mother's Father
Question | Response | Comment/Age Affected |
Current age or age at death | 55 | |
Health Problem | Heart disease, treatment unknown | 52 |
Heart attack, fatal, no treatment | 55 | |
Cause of death: Heart attack | 55 | |
Living / Dead | Dead |
Your Mother's Mother
Question | Response | Comment/Age Affected |
Current age or age at death | 75 | |
Health Problem | Rheumatoid arthritis and osteoarthritis, mild, no treatment currently | 60 |
Living / Dead | Living |
Your Mother's Brothers 1
Question | Response | Comment/Age Affected |
Current age or age at death | 16 | |
Health Problem | Healthy | |
Cause of death: Gunshot (murdered) | 16 | |
Living / Dead | Dead |
Your Mother's Brothers 2
Question | Response | Comment/Age Affected |
Current age or age at death | 50 | |
Health Problem | Healthy | |
Living / Dead | Living |
Your Father's Father
Question | Response | Comment/Age Affected |
Current age or age at death | 80 | |
Health Problem | Parkinson's, managed with medication and assisted care | 75 |
Living / Dead | Living |
Your Father's Mother
Question | Response | Comment/Age Affected |
Current age or age at death | 74 | |
Health Problem | Lung cancer (smoker), treated with chemotherapy and radiation | 71 |
Cause of death: Lung cancer, metastasized to the liver | 74 | |
Living / Dead | Dead |
Your Father's Sisters 1
Question | Response | Comment/Age Affected |
Current age or age at death | 43 | |
Health Problem | Healthy | |
Living / Dead | Living |