Personal Behavior History
Donor Sexual History
Donor Genetic History
Donor Medical History
Family Medical HistoryThis 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: | Regularly - 30 oz wine/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? | Yes |
| 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: | Yes - 1 kidney, Mother |
| 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 - 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 - non-carrier by gene sequencing |
| If yes, result: | Non Carrier |
| Are you of Mediterranean, Greek or Italian ancestry? | No |
| If yes, have you been tested as a carrier of beta thalassemia? | Yes - non-carrier by gene sequencing |
| If yes, result: | Non Carrier |
Donor Medical History
| Question | Response |
| List any operations: Age & reason: | Wisdom teeth extraction at age 16, Wisdom teeth extraction at age 22, Spleen removed at age 22 after rupture due to Mononucleosis infection |
| 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 - Broken thumb at age 12, sports-related injury; Collar Bone at age 23 due to bicycle accident; Broken Arm at age 31 due to bicycle accident |
| 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: | 1 - Cold |
| 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: | N/A - None |
| List all current medication or treatments (include vitamins, aspirin, antacids, laxatives, herbal, sports supplements, etc.) Include drug, frequency and duration taken, and reason: | N/A - None |
| Do you wear glasses or contact lenses? Are you near or far-sighted? | Yes - far-sighted |
| Usual weight? | 218 |
| 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? | 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 HistorySee list of questions asked here
Your Mother
| Question | Response |
| Current age or age at death | 59 |
| 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
50
Exercsie and lifestyle changes
Missing one kidney
From birth. Donor's kidney scan is normal.
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
Healthy
Brothers
Your Brother 1
| Question | Response |
| Current age or age at death | 28 |
| 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 | 30 |
| 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 | 69 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Complications due to Diabetes |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Heart attack
70
Surgical, stent placed
High blood pressure
60
Medication
Diabetes mellitus requiring insulin therapy
60
Insulin
Your Mother's Mother
| Question | Response |
| Current age or age at death | 72 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Emphysema |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Heart attack
60
Hospitilzation monitoring and quit smoking
Emphysema
72
Oxygen
Your Mother's Sisters 1
| Question | Response |
| Current age or age at death | 70 |
| 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 | 69 |
| 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 | 66 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Obesity
50
Surgery (gastric bypass)
Your Mother's Sisters 4
| Question | Response |
| Current age or age at death | 42 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Organ failure due to diabetes complications |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Diabetes mellitus requiring insulin therapy
8
Insulin
Heart attack (complication of diabetes)
35
Medication
Progressive kidney disease (complication of diabetes)
40
Dialysis
Your Mother's Sisters 5
| 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 1
| Question | Response |
| Current age or age at death | 1 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Untreated infant pneumonia |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Pneumonia
1
Untreated, during war time
Your Mother's Brothers 2
| Question | Response |
| Current age or age at death | 0.1 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Untreated Infant dysentery |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Dysentery at 2 weeks of age
No treatment, during war time
Your Father's Father
| Question | Response |
| Current age or age at death | 78 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Liver Cancer |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Liver Cancer
76
No treatment (terminal)
Prostate cancer
72
Chemotherapy, Radiation
Your Father's Mother
| 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
Osteoarthritis
75
Ibuprofen
Skin cancer
55
Removed
Your Father's Sisters 1
| 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
Disease
Age Diagnosed
Treatment For Condition
Multiple sclerosis (Clinically isolated)
35
Medication
Your Father's Brothers 1
| 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
Disease
Age Diagnosed
Treatment For Condition
Leukemia
8
Bone marrow transplant