Personal Behavior History
Question | Response |
Current alcohol use: If yes, oz./week and type of alcohol: | Regularly - 36 oz. beer/week |
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? | N/A |
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? | Yes |
Any dietary restrictions? If yes, explain: | No - But pescatarian by choice |
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 |
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 |
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 |
Donor Medical History
Question | Response |
List any operations: Age & reason: | Knee tendon repair, age 26, from hiking trip |
Hospitalization other than surgery: Age & type of illness: | Broken arm, age 26 |
Have you ever had any broken bones? If yes, please give age and description: | Yes - Arm, age 26, bike accident |
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 - Colds |
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: | Tylenol/Aleve/ibuprofen, taken as needed for soreness, headaches; Benadryl, taken for spring allergies |
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? | No - (Near-sighted before laser surgery) |
Usual weight? | 150 |
Recent weight loss or gain? # of lbs and reason: | No |
Allergies (medicines, food, pollens)? If yes, please list substance and reaction caused: | Yes - Pollen: Causes itchy eyes |
Have you been tested for HIV (AIDS)? If yes, when: | Yes - Negative, ongoing donor screening |
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 - 2014 |
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 |
Current age or age at death | 62 |
Living / Dead | Living |
Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Your Father
Question | Response |
Current age or age at death | 65 |
Living / Dead | Living |
Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Brothers
Your Brother 1
Question | Response |
Current age or age at death | 29 |
Living / Dead | Living |
Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Sisters
Your Sister 1
Question | Response |
Current age or age at death | 33 |
Living / Dead | Living |
Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Your Sister 2
Question | Response |
Current age or age at death | 26 |
Living / Dead | Living |
Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Your Mother's Father
Question | Response |
Current age or age at death | 94 |
Living / Dead | Living |
Cause of death and any treatment prior to death | N/A |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Dementia
90
Assisted care
Your Mother's Mother
Question | Response |
Current age or age at death | 39 |
Living / Dead | Dead |
Cause of death and any treatment prior to death | Breast cancer |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Breast cancer
39
None
Your Mother's Brothers 1
Question | Response |
Current age or age at death | 56 |
Living / Dead | Living |
Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Your Father's Father
Question | Response |
Current age or age at death | 78 |
Living / Dead | Dead |
Cause of death and any treatment prior to death | Heart attack |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
High cholesterol in his mid-70s
None
High blood pressure in his mid-70s
None
Heart attack
78
None
Your Father's Mother
Question | Response |
Current age or age at death | 39 |
Living / Dead | Dead |
Cause of death and any treatment prior to death | Suicide |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Healthy (no history of depression or mental illness)
N/A
Your Father's Sisters 1
Question | Response |
Current age or age at death | 61 - Paternal half sister |
Living / Dead | Living |
Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Your Father's Brothers 1
Question | Response |
Current age or age at death | 21 |
Living / Dead | Dead |
Cause of death and any treatment prior to death | Car accident |
Health Problems
Healthy