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? | No |
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 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 |
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: | Ear tubes, age 2, for ear infections; Tonsillectomy/adenoidectomy, age 16, due to infections; Wisdom teeth removal, age 17 |
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: | Yes - Asthma (mild) |
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: | Cetirizine, taken as needed for seasonal allergies; Ibuprofen, taken as needed for pain relief; Vitamin D, taken daily during winter months; Multivitamin, taken daily; Beclomethasone (inhaler), used twice per day, for asthma |
List all current medication or treatments (include vitamins, aspirin, antacids, laxatives, herbal, sports supplements, etc.) Include drug, frequency and duration taken, and reason: | Beclomethasone (inhaler), used twice per day, for asthma; Multivitamin, taken daily |
Do you wear glasses or contact lenses? Are you near or far-sighted? | No - (Near-sighted before laser surgery) |
Usual weight? | 165 |
Recent weight loss or gain? # of lbs and reason: | No |
Allergies (medicines, food, pollens)? If yes, please list substance and reaction caused: | Yes - Dust mites: Asthma trigger; Seasonal allergies: Cause typical symptoms |
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? | 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 |
Current age or age at death | 60 |
Living / Dead | Living |
Cause of death and any treatment prior to death | N/A |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Irritable Bowel Syndrome
55
Diet modification
Your Father
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
Disease
Age Diagnosed
Treatment For Condition
Red-green color blindness (No other family members affected)
12
None
Skin cancer
55
Surgery, Blue light treatment
Brothers
Your Brother 1
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
Sisters
Your Sister 1
Question | Response |
Current age or age at death | 32 |
Living / Dead | Living |
Cause of death and any treatment prior to death | N/A |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Bulimia (resolved)
18
Therapy
Your Sister 2
Question | Response |
Current age or age at death | 24 |
Living / Dead | Living |
Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Sons
Your Son 1
Question | Response |
Current age or age at death | 1 |
Living / Dead | Living |
Health Problems
Healthy
Your Mother's Father
Question | Response |
Current age or age at death | 90 |
Living / Dead | Dead |
Cause of death and any treatment prior to death | Congestive heart failure |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Stroke
41
None
Transient ischemic attack
55
Medication
Osteoarthritis
63
None
Diabetes mellitus not requiring insulin therapy
70
Medication
High cholesterol
75
Medication
Heart attack
75
Quadruple bypass surgery
Meningitis
82
Hospitalized
Congestive heart failure
90
None
Your Mother's Mother
Question | Response |
Current age or age at death | 84 |
Living / Dead | Dead |
Cause of death and any treatment prior to death | Pancreatic cancer |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Chronic Obstructive Pulmonary Disease (smoker)
75
Oxygen
Pancreatic cancer
84
None
Your Mother's Brothers 1
Question | Response |
Current age or age at death | 64 |
Living / Dead | Living |
Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Your Mother's Brothers 2
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
Disease
Age Diagnosed
Treatment For Condition
Obesity
30
Diet
Your Mother's Brothers 3
Question | Response |
Current age or age at death | 58 |
Living / Dead | Living |
Cause of death and any treatment prior to death | N/A |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Obesity
40
None
Your Father's Father
Question | Response |
Current age or age at death | 84 |
Living / Dead | Living |
Cause of death and any treatment prior to death | N/A |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Skin cancer
52
Surgery
Your Father's Mother
Question | Response |
Current age or age at death | 78 |
Living / Dead | Dead |
Cause of death and any treatment prior to death | Renal failure |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Diabetes mellitus requiring insulin therapy
60
N/A
Renal failure
74
None
Your Father's Sisters 1
Question | Response |
Current age or age at death | 58 |
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 | 62 |
Living / Dead | Living |
Cause of death and any treatment prior to death | N/A |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Detached retina
60
Surgery
Your Father's Brothers 2
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
Disease
Age Diagnosed
Treatment For Condition
Alcohol abuse
40
None