Personal Behavior History

Question Response
Current alcohol use:
If yes, oz./week and type of alcohol:
Frequently - 2 oz/wk, vodka
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

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 karyotpye
Spinal Muscular Atrophy (SMA)?
If yes, the result:
Non Carrier - by gene sequencing
Tay Sachs?
If yes, the result:
Non Carrier - by gene sequencing
Question Response
Are you of Jewish ancestry?
If yes, please note: Ashkenazi, Sephardi, or Other
No
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
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:
Wisdom teeth removed - age 15
Hospitalization other than surgery:
Age & type of illness:
No
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:Creatine monohydrate 3x/wk to increase muscle growth, daily vitamin
List all current medication or treatments (include vitamins, aspirin, antacids, laxatives, herbal, sports supplements, etc.) Include drug, frequency and duration taken, and reason:Daily vitamin, creatine monohydrate 3x/wk (6 months, to increase muscle growth)
Do you wear glasses or contact lenses?
Are you near or far-sighted?
Yes - Astigmatism
Usual weight?209
Recent weight loss or gain?
# of lbs and reason:
Yes - 25 lbs., just to be healthier
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 History
See list of questions asked here

Question Response
Current age or age at death 56
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Question Response
Current age or age at death 60
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Question Response
Current age or age at death 25
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Question Response
Current age or age at death 88
Living / DeadDead
Cause of death and any treatment prior to deathStroke
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Stroke
88
Fatal
Question Response
Current age or age at death 90
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Stroke
88
No treatment
Question Response
Current age or age at death 53
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Question Response
Current age or age at death 92
Living / DeadDead
Cause of death and any treatment prior to deathHeart attack
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Heart Attack
92
Fatal
Question Response
Current age or age at death 90
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Question Response
Current age or age at death 64
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Question Response
Current age or age at death 58
Living / DeadLiving
Cause of death and any treatment prior to deathN/A
Health Problems
Healthy
Question Response
Current age or age at death 55
Living / DeadDead
Cause of death and any treatment prior to deathCar accident
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Healthy
 
No existing health issues at time of death