This donor is a healthy carrier for a genetic disease.
Please see his Genetic Testing Summary and Acknowledgment of Genetic Risk for details
Please see his Genetic Testing Summary and Acknowledgment of Genetic Risk for details
Personal Behavior History
Question | Response |
Current alcohol use: If yes, oz./week and type of alcohol: | Frequently - 24 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
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: | Tonsillectomy, age 6; Two wisdom teeth extracted, age 23 |
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: | Caffeine supplement, Garlic supplement, both taken daily; Arginine, taken on workout days (3-4 days/week) |
List all current medication or treatments (include vitamins, aspirin, antacids, laxatives, herbal, sports supplements, etc.) Include drug, frequency and duration taken, and reason: | Caffeine supplement, Garlic supplement, both taken daily |
Do you wear glasses or contact lenses? Are you near or far-sighted? | Yes - Astigmatism |
Usual weight? | 228 |
Recent weight loss or gain? # of lbs and reason: | Yes - +15 pounds, promotion led to less physical activity at work |
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? | 1 |
Have you ever had a tattoo? If yes, what year did you get the tattoo? | Yes - Most recently in 2014 |
Have you ever had your ear(s) or body pierced? If yes, where and what year? | Yes - Chest and frenulum in 2017 |
Family Medical HistorySee list of questions asked here
Your Mother
Question | Response |
Current age or age at death | 54 |
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 | 57 |
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 | 36 - Paternal half brother |
Living / Dead | Living |
Cause of death and any treatment prior to death | N/A |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Situational anxiety
36
None
Your Brother 2
Question | Response |
Current age or age at death | 32 - Paternal half brother |
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 | 3 |
Living / Dead | Living |
Health Problems
Healthy
Your Mother's Father
Question | Response |
Current age or age at death | 72 |
Living / Dead | Dead |
Cause of death and any treatment prior to death | Lung cancer |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Lung cancer (smoker)
72
None
Your Mother's Mother
Question | Response |
Current age or age at death | 76 |
Living / Dead | Dead |
Cause of death and any treatment prior to death | Colon cancer |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Colon cancer
75
Refused treatment
Your Mother'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 Mother's Sisters 2
Question | Response |
Current age or age at death | 55 - (Twin to maternal uncle #3) |
Living / Dead | Living |
Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Your Mother's Sisters 3
Question | Response |
Current age or age at death | 54 - (Identical twin to donor's mother) |
Living / Dead | Living |
Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Your Mother's Sisters 4
Question | Response |
Current age or age at death | 52 |
Living / Dead | Living |
Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Your Mother'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 Mother's Brothers 2
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 Mother's Brothers 3
Question | Response |
Current age or age at death | 55 - (Twin to maternal aunt #2) |
Living / Dead | Living |
Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Your Mother's Brothers 4
Question | Response |
Current age or age at death | 14 |
Living / Dead | Dead |
Cause of death and any treatment prior to death | Trauma |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Trauma (struck by a vehicle while walking)
14
None
Your Father's Father
Question | Response |
Current age or age at death | 88 |
Living / Dead | Living |
Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Your Father's Mother
Question | Response |
Current age or age at death | 85 |
Living / Dead | Living |
Cause of death and any treatment prior to death | N/A |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
High blood pressure, in her early 70s
Medication
Your Father's Sisters 1
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
Your Father's Sisters 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
Healthy
Your Father's Sisters 3
Question | Response |
Current age or age at death | 52 |
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 | 61 |
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 | 60 |
Living / Dead | Living |
Cause of death and any treatment prior to death | N/A |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Rheumatic fever
5
Medication
Your Father'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
Healthy
Your Father's Brothers 4
Question | Response |
Current age or age at death | 54 |
Living / Dead | Living |
Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy