Personal Behavior History

Question Response
Current alcohol use:
If yes, oz./week and type of alcohol:
Regularly - 24 oz. beer and 1-2 oz. liquor/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?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

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
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

Donor Medical History

Question Response
List any operations:
Age & reason:
Tonsillectomy at age 8; Wisdom teeth extraction at age 20
Hospitalization other than surgery:
Age & type of illness:
Broken clavicle, twice, at age 13 (three months apart from each other)
Have you ever had any broken bones?
If yes, please give age and description:
Yes - Broken clavicle (twice) at age 13, 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:Flonase, used as needed for allergies
List all current medication or treatments (include vitamins, aspirin, antacids, laxatives, herbal, sports supplements, etc.) Include drug, frequency and duration taken, and reason:Flonase, used as needed for allergies
Do you wear glasses or contact lenses?
Are you near or far-sighted?
No
Usual weight?177
Recent weight loss or gain?
# of lbs and reason:
No
Allergies (medicines, food, pollens)?
If yes, please list substance and reaction caused:
Yes - Pet dander, mold, dust: Cause sniffles, sneezing and watery eyes; Ceclor: Causes rash
Have you been tested for HIV (AIDS)?
If yes, when:
Yes - Negative, ongoing donor screening
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 History
See list of questions asked here

Question Response
Current age or age at death 58
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Gallstones, age 44 or 45
 
Surgery
Double vision, due to recent car accident
58
None yet; considering corrective surgery
Question Response
Current age or age at death 67
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Question Response
Current age or age at death 32
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Question Response
Current age or age at death 30
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Question Response
Current age or age at death 80
Living / DeadDead
Cause of death and any treatment prior to deathComplications of diabetes
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Diabetes (Type 2) requiring insulin therapy
57
N/A
Question Response
Current age or age at death 63
Living / DeadDead
Cause of death and any treatment prior to deathHeart attack
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Heart attack, fatal
63
None
Question Response
Current age or age at death 66
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Question Response
Current age or age at death 40
Living / DeadDead
Cause of death and any treatment prior to deathTrauma
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Trauma (accidental fall)
40
None
Question Response
Current age or age at death 61
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Question Response
Current age or age at death 65
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Stroke, minor
62
Unknown
Question Response
Current age or age at death 64
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Question Response
Current age or age at death 62
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Question Response
Current age or age at death 56
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Alcoholism
35
Rehabilitation clinic, several times
Question Response
Current age or age at death 78
Living / DeadDead
Cause of death and any treatment prior to deathCoronary artery disease
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Coronary artery disease, in his early 70s
 
Medication, bypass surgery
Question Response
Current age or age at death 75
Living / DeadDead
Cause of death and any treatment prior to deathStomach cancer
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Stomach cancer, in her late 60s
 
Radiation, chemotherapy
Question Response
Current age or age at death 68
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Question Response
Current age or age at death 64
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy