Personal Behavior History
Question | Response |
Current alcohol use: If yes, oz./week and type of alcohol: | Rarely - 24 oz. beer/month |
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 |
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: | Tonsillectomy, age 20; Wisdom teeth removal, age 22; Pectoral muscle repair, age 27, 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: | 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: | Tylenol taken for three days for sore knee; Ambien taken as needed for better sleep; Multivitamin taken daily |
List all current medication or treatments (include vitamins, aspirin, antacids, laxatives, herbal, sports supplements, etc.) Include drug, frequency and duration taken, and reason: | Multivitamin taken daily |
Do you wear glasses or contact lenses? Are you near or far-sighted? | No |
Usual weight? | 220 |
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 |
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 - 2003-2014 |
Have you ever had your ear(s) or body pierced? If yes, where and what year? | Yes - Ear in 1999 |
Family Medical HistorySee list of questions asked here
Your Mother
Question | Response |
Current age or age at death | 60 |
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 | 63 |
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 | 24 - Maternal half brother |
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 | 65 |
Living / Dead | Dead |
Cause of death and any treatment prior to death | Stroke |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Stroke (smoker and drinker)
65
None
Your Mother's Mother
Question | Response |
Current age or age at death | 90 |
Living / Dead | Dead |
Cause of death and any treatment prior to death | Complications of stroke |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Atrial fibrillation
75
Blood thinners
Broken arm (and so taken off of blood thinners)
90
Hospitalized
Stroke (she died about six weeks later of complications)
90
Hospice care
Your Mother's Brothers 1
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
Your Father's Father
Question | Response |
Current age or age at death | 84 |
Living / Dead | Dead |
Cause of death and any treatment prior to death | Ruptured aorta |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Ruptured aorta
84
None
Your Father's Mother
Question | Response |
Current age or age at death | 90 |
Living / Dead | Dead |
Cause of death and any treatment prior to death | Natural causes |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Low blood pressure (mild)
70
Medication
Your Father's Sisters 1
Question | Response |
Current age or age at death | 61 |
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 | 60 |
Living / Dead | Living |
Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Your Father's Brothers 2
Question | Response |
Current age or age at death | 57 |
Living / Dead | Living |
Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Your Father's Brothers 3
Question | Response |
Current age or age at death | 55 |
Living / Dead | Living |
Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy