Personal Behavior History
Donor Sexual History
Donor Genetic History
Donor Medical History
Family Medical HistoryPersonal Behavior History
| Question | Response |
| Current alcohol use: If yes, oz./week and type of alcohol: | Frequently - 12-24 oz beer twice per 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: | Surgery on broken nose age 10; wisdom teeth (4) removal age 21; surgery to fix labrum/rotator cuff from car accident age 37 |
| Hospitalization other than surgery: Age & type of illness: | None |
| Have you ever had any broken bones? If yes, please give age and description: | Yes - Broke right wrist age 7, sports related injury; Broken nose age 10, sports related injury; Fractured Sternum age 37, car 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: | 240 - Out on workers compensation since car accident resulted in torn Labrum/Rotator Cuff. |
| Are you presently under a physician's care for any reason? If yes, please describe: | Yes - Currently receiving care for torn Labrum/Rotator cuff. |
| 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: | Garcinia Combogia 1000 mg 4 times daily since August 2019 for health; Dandelion Root 500 mg 2 times daily since August 2019 for health; Maca 500 mg 2 times daily since September 2017 for health; L-Arginine 400 mg 2 times daily since September 2017 for health; L-Lysine 2000 mg 2 times daily since September 2017 for health; Ashwagandha 450 mg 1 time daily since September 2017 for health; Nettle leaf 870 mg 1 time daily since September 2017 for health; Meloxicam 15 mg daily for 30 days in April 2019 for pain management prior to surgery; Methocarbam 500 mg for 30 days in April 2019 for pain management; Celecoxib 200 mg twice daily from August to September 2019; Gabapentin 100 mg three times daily from January to March 2020 for pain after surgery; Naproxen sodium 550 mg twice dialy from March to July 2020 for shoulder pain; Gabapentin 300 mg three times daily from July 2020 to present for pain management. |
| List all current medication or treatments (include vitamins, aspirin, antacids, laxatives, herbal, sports supplements, etc.) Include drug, frequency and duration taken, and reason: | Garcinia Combogia 1000 mg 4 times daily since August 2019 for health; Dandelion Root 500 mg 2 times daily since August 2019 for health; Maca 500 mg 2 times daily since September 2017 for health; L-Arginine 400 mg 2 times daily since September 2017 for health; L-Lysine 2000 mg 2 times daily since September 2017 for health; Ashwagandha 450 mg 1 time daily since September 2017 for health; Nettle leaf 870 mg 1 time daily since September 2017 for health; Gabapentin 300 mg three times daily from July 2020 to present for pain management. |
| Do you wear glasses or contact lenses? Are you near or far-sighted? | No |
| Usual weight? | 175 |
| 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? | 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? | Yes - Ear, 2020 |
Family Medical HistorySee list of questions asked here
Your Mother
| Question | Response |
| Current age or age at death | 71 |
| 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 | 74 |
| 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
65
Lisinopril 20 mg daily
Seasonal Allergies
22
No treatment
Brothers
Your Brother 1
| Question | Response |
| Current age or age at death | 47 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Your Brother 2
| Question | Response |
| Current age or age at death | 36 |
| 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 | 49 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Your Sister 2
| Question | Response |
| Current age or age at death | 40 |
| 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 | 4 |
| Living / Dead | Living |
Health Problems
Healthy
Daughters
Your Daughter 1
| Question | Response |
| Current age or age at death | 8 |
| Living / Dead | Living |
Health Problems
Healthy
Your Mother's Father
| Question | Response |
| Current age or age at death | 92 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Heart Attack |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Broken collar bone due to fall
84
No treatment
Heart Attack
92
None, fatal
Your Mother's Mother
| Question | Response |
| Current age or age at death | 90 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Heart attack |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Heart Attack
90
None, fatal
Your Mother's Sisters 1
| 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 2
| Question | Response |
| Current age or age at death | 5 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Seizures caused by birth trauma |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Nuchal cord birth injury
No treatment
Your Mother's Brothers 1
| Question | Response |
| Current age or age at death | 67 |
| 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 | 64 |
| 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 | 79 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Fall in apartment |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Idiopathic thrombocytopenic pupura
79
No treatment, diagnosed post mortem
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 | Heart attack |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Breast cancer
68
Mastectomy
Breast cancer recurrence
78
No treatment
Your Father's Sisters 1
| Question | Response |
| Current age or age at death | 82 |
| 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 | 54 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Ovarian cancer |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Ovarian cancer
54
No treatment
Your Father's Brothers 1
| Question | Response |
| Current age or age at death | 67 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy