Personal Behavior History

Question Response
Current alcohol use:
If yes, oz./week and type of alcohol:
Rarely - 4 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?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 by gene sequencing
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, age 14
Hospitalization other than surgery:
Age & type of illness:
N/A
Have you ever had any broken bones?
If yes, please give age and description:
Yes - Right wrist at age 11, tripped and fell
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 rarely for pain, soreness, or headache
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
Usual weight?193
Recent weight loss or gain?
# of lbs and reason:
No
Allergies (medicines, food, pollens)?
If yes, please list substance and reaction caused:
Yes - Tree nuts: Cause emesis
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 - 2011
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 50
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Chronic depression
28
Medication, Exercise
High blood pressure
45
Medication
Question Response
Current age or age at death 46
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Question Response
Current age or age at death 23
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Question Response
Current age or age at death 20
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Question Response
Current age or age at death 14
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Question Response
Current age or age at death 19
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Question Response
Current age or age at death 17
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Question Response
Current age or age at death 15
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Question Response
Current age or age at death 12
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Question Response
Current age or age at death 1
Living / DeadLiving
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Respiratory syncytial virus
1
Hospitalization, made full recovery
Question Response
Current age or age at death 0 - (stepdaughter)
Living / DeadLiving
Health Problems
Disease
Age Diagnosed
Treatment For Condition
N/A
 
N/A
Question Response
Current age or age at death 66
Living / DeadDead
Cause of death and any treatment prior to deathTrauma
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Trauma due to motorcycle accident
66
None
Question Response
Current age or age at death 70
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Polio
15
Physical therapy, Assorted management devices
Question Response
Current age or age at death 48
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Ovarian cysts
35
Hysterectomy
Question Response
Current age or age at death 44
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 / 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
Disease
Age Diagnosed
Treatment For Condition
Prostate cancer
56
Chemotherapy
Question Response
Current age or age at death 55
Living / DeadDead
Cause of death and any treatment prior to deathComplications of diabetes
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Diabetes mellitus requiring insulin therapy
20
N/A
Question Response
Current age or age at death 42
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Diabetes
35
Managed with diet
Question Response
Current age or age at death 34
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy