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: | Occasionally - 16-32oz, beer |
| 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: | Yes - Birth mark on scalp. Cosmetic, removed. |
| 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: | Soft tissue repair in right knee at age 23; Removal of gangreous tissue from lower intestine from sports related injury at age 27; Torn labrum repair in hip sports related injury age 35; Rhinoplasty septum repair due to sports related injury age 35 |
| 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 right Patella between age 15 and 25 |
| 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: | 21 - Hip surgery performed, took additional week off. |
| 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: | Anti-inflammatory and pain management - Meloxocam taken 2-3 times a week for 10 years for inflammation, Hydrocodone taken 3 times a day for 2 weeks following surgery, Azelastine HCl & Fluticosone Nasal Spray taken 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: | Anti-inflammatory - Meloxocam taken 2-3 times a week for 10 years for inflammation related to sports injuries, Azelastine Hcl and Fluticasone Nasal spray taken as needed for allergies, |
| Do you wear glasses or contact lenses? Are you near or far-sighted? | No |
| Usual weight? | 255 |
| Recent weight loss or gain? # of lbs and reason: | Yes - 20 lbs gained during quarantine |
| Allergies (medicines, food, pollens)? If yes, please list substance and reaction caused: | Yes - Iodine, latex: contact allergy. Seasonal Allergies |
| 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
Healthy
Your Father
| 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
Disease
Age Diagnosed
Treatment For Condition
Pre-Diabetic
63
Metformin
Chronic knee pain
63
Right Knee replacement
Your Mother's Father
| Question | Response |
| Current age or age at death | 70 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Anuerysm |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Anuerysm
70
Immediately fatal
Your Mother's Mother
| Question | Response |
| Current age or age at death | 70 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Amyotrophic lateral sclerosis (ALS) |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Amyotrophic lateral sclerosis (ALS)
58
Received standard treatment at the time
Your Mother's Sisters 1
| 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
Healthy
Your Father's Father
| Question | Response |
| Current age or age at death | 83 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Aneurysm |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Aneurysm
83
Immediately fatal
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
Benign Brain tumor
80
No treatment
Your Father's Sisters 1
| Question | Response |
| Current age or age at death | 50 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Car Accident |
Health Problems
Healthy
Your Father's Brothers 1
| Question | Response |
| Current age or age at death | 20 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Vietnam casualty |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Trauma from war injury
20
None