| Fairfax Cryobank |
| Sample Donor Medical Profile |
| Do you or any member of your family have any of the following? | ||
| QUESTION | RESPONSE | RELATION AND AGE AFFECTED |
| Down's Syndrome (Mongolism) | No | |
| club foot | No | |
| cleft lip or cleft palate | No | |
| congenital heart disease | No | |
| pyloric stenosis | No | |
| neural tube defects (open spine or water on the brain) | No | |
| PKU or inherited metabolic disorder | No | |
| progressive kidney disease | No | |
| polycystic kidney disease | No | |
| diabetes mellitus not requiring insulin therapy | No | |
| diabetes mellitus requiring insulin therapy | No | |
| premature degeneration of any organ system | No | |
| cataracts before age 40 | No | |
| cataracts before age 60 | No | |
| blindness in both eyes before age 60 | No | |
| loss of muscle coordination | No | |
| muscular dystrophy | No | |
| schizophrenia | No | |
| manic depressive psychosis | No | |
| mental deterioration or senility before age 60 | Yes | 1 cousin--father's side birth |
| mental retardation | No | |
| epilepsy or seizure disorder | No | |
| alpha-1 antitrypsin disorder | No | |
| Parkinson's disease | No | |
| rheumatiod arthritis | No | |
| hemophilia | No | |
| psoriasis | No | |
| drug abuse problem | No | |
| migraines | No | |
| glaucoma | No | |
| genital herpes simplex virus | No | |
| inguinal hernia | No | |
| heritable birth defects | No | |
| Huntington's disease | No | |
| two or more miscarriages or stillborn | No | |
| tuberous sclerosis | No | |
| neurofibromatosis | No | |
| more than five coffee-colored spots on the skin (size of a quarter or larger) or numerous lumps under the skin | No | |
| heart attack (less than 50) or has a relative died early | Yes | grandmother & grandfather on father's side car accident |
| cystic fibrosis | No | |
| same cancer in more than one family member | No | |
| servere bleeding tendency | No | |
| albinism | No | |
| Reiter's disease | No | |
| inflammatory bowel disease | No | |
| Have you ever had? | |
| QUESTION | RESPONSE |
| syphilis | No |
| genital herpes | No |
| hepatitis B,C, other | No |
| orchitis | No |
| epididymitis | No |
| prostatis | No |
| mumps with testes invovled | No |
| urethritis | No |
| varicocele | No |
| Creutzfeldt-Jacob disease | No |
| hydrocele | No |
| blood transfusion | No |
| prolonged fever | No |
| fever above 101 degrees (in the past three months) | No |
| genital warts/papillomavirus | No |
| liver disease | No |
| renal disease | No |
| diabetes | No |
| psychiatric disorders | No |
| undescended testicle | No |
| tuberculosis | No |
| multiple sclerosis | No |
| Have you experienced the following condition(s) on a regular basis? | ||
| QUESTION | RESPONSE | COMMENTS |
| rashes, color change | No | |
| itching | No | |
| excessive sweating | No | |
| minor injury | Yes | stitches 9 years ago |
| lymp node or gland swelling | No | |
| ear trouble, infection | No | |
| nosebleeds | No | |
| stuffy nose, sinus trouble, hay fever | No | |
| sore throats | No | |
| hoarseness | No | |
| dental or gum problems | No | |
| shortness of breath | No | |
| cough, chest colds | No | |
| bringing up sputum with blood | No | |
| fever, sweats, chills | No | |
| fast or irregular heartbeat | No | |
| frequent urinating | No | |
| waking to urinate (#times / night) | No | |
| sores or discharge | No | |
| bleeding or bruising | No | |
| trouble swallowing | No | |
| poor appetite | No | |
| gas, cramps, pain | No | |
| heartburn, indigestion | No | |
| nausea, vomiting, constipation, diarrhea | No | |
| back pain, neck pain | No | |
| headaches | No | |
| poor sleeping | No | |
| nervousness, tension | No | |
| trouble thinking, remembering | No | |
| crying, upset, worrying | No | |
| Have you had the following condition(s) now or in the past? | ||
| QUESTION | RESPONSE | |
| warts, moles | Yes | |
| eczema, lumps, hives | No | |
| very dry skin | No | |
| anemia | No | |
| hearing loss, ringing in ear | No | |
| eyes problems | Yes | |
| enlarged or painful breasts | No | |
| breasts lumps | No | |
| discharge from nipples | No | |
| wheezing, asthma | No | |
| chest pain, pleurisy | No | |
| TB or exposure to TB | No | |
| pneumonia | No | |
| chest pain, tightness, pressure | No | |
| trouble breathing when lying down | No | |
| waking short of breath | No | |
| swelling of feet or ankles | No | |
| previous heart trouble | No | |
| murmurs or rheumatic fever | No | |
| high blood pressure | No | |
| poor circulation, varicose veins | No | |
| blood clots | No | |
| blood in stool or black stool | No | |
| yellow jaundice, hepatitis | No | |
| hemorrhoids | No | |
| hernia | No | |
| gall bladder problems | No | |
| pains in joints, arthritis | No | |
| swollen joints | No | |
| head injury, concussion | No | |
| convulsions, seizures, fits | No | |
| shaking, tremor | No | |
| weakness, paralysis | No | |
| numbness, tingling | No | |
| difficulty walking, coordination | No | |
| depression, anxiety | No | |
| sexual problems | No | |
| cancer | No | |
| diabetes | No | |
| goiter, thyroid problems | No | |
| Other Questions | ||
| QUESTION | RESPONSE | COMMENTS |
| Alcohol use? If yes, how much? | Occasionally | 6 beers/week |
| Any relatives with alcoholism? If yes, who? | No | |
| Tobacco use? If yes, # of packs/day, date quit, for how many years. | No | |
| Have you had sex with another man in the preceding 5 years? | No | |
| Have you had sex with a person having non-medical intravenous, intramuscular, or subcutaneous injection of drugs in the preceding 5 years? | No | |
| Have you had sex with a person who has engaged in sex in exchange for money or drugs in the preceding 5 years? | No | |
| Have you had sex with a person who has had sex with another person described in any of the above in the preceding 12 months? | No | |
| Have you ever been convicted of a felony? If yes, explain. | No | |
| Do you sleep well? | Yes | |
| Do you exercise on a regular basis? | Yes | |
| Is your diet well balanced? Explain if needed. | Yes | |
| Any dietary restrictions? Explain. | No | |
| Have you been exposed to known or suspected HIV-infected blood through percutaneous inoculation or through contact with an open wound, non-intact skin, or mucous membrane within the preceding 12 months? | No | |
| Were you born with any birth defects (heart defect, cleft lip or palate, club feet, other)? If yes, please explain. | No | |
| Are there any known genetic conditions or birth defects in your family? If yes, please explain. | No | |
| Have you been tested for Cystic Fibrosis? If yes, the result? | Yes | during Donor Screening process - noncarrier |
| Have you been tested for Alpha-1 Antitrypsin Disorder? If yes, the result? | Yes | during Donor Screening process - noncarrier |
| Are you of Jewish ancestry? | No | |
| Have you been tested for BRCA -1( breast and ovarian cancer)? If yes, the result? | N/A | |
| Have you been tested as a carrier for Tay Sachs? If yes, the result. | N/A | |
| Have you been tested as a carrier for Gaucher? If yes, the results. | N/A | |
| Have you been tested as a carrier for Canavan? If yes, the results. | N/A | |
| Are you of African ancestry? | No | |
| Have you been tested as a carrier for Sickle Cell disease? If yes, the results. | N/A | |
| Are you of Mediterranean (Greek or Italian) ancestry? | No | |
| Have you been tested as a carrier of thalassemia? If yes, result? | N/A | |
| Have you had any operations? If yes, type and year: | Yes | 21 years ago cut head required sutures 13 years cut hand that required sutures |
| Have you been hospitalized other than for surgery? If yes, year and type and illness: | No | |
| Have you ever had any broken bones? If yes, please describe: | No | |
| Have you ever had any serious illnesses? If yes, please explain: | Yes | Mumps age 4 |
| Are you presently under a physician's care for any reason? If yes, please describe: | No | |
| Have you ever had occupational exposure to radiation or chemicals? If yes, please describe: | No | |
| List all drugs, prescription, non-prescription, & "recreational" you have taken in the past 12 months. If yes, type, how often and reason: | Yes | Sudafed 3 times cold, runny nose |
| List all current medications or treatments (include vitamins, aspirin, antacids, laxatives, etc.) If yes, type, how often and reason: | Yes | Vitamins daily dietary supplement |
| How many days in the past 12 months could you not work because of all illness (colds, flu, accidents, surgery, etc.)? | One | |
| Do you wear glasses or contact lenses? | Yes | |
| Usual weight? | 195 lbs. | |
| Recent weight loss or gain? If yes, how much? | No | |
| Allergies (medicines, food, pollens)? If yes, list kind: | No | |
| Have you ever been refused as blood donor? If yes, why? | No | |
| Have you been tested for HIV (AIDS) prior to applying to this program? If yes, when, the results and the reason for testing: | No | |
| Sexual preference: | Heterosexual | |
| Number of current sexual partners: | None | |
| Has any sexual partner been positive for HIV (AIDS)? If yes, explain: | No | |
| Has any sexual partner had an episode of trichomoniasis? If yes, explain? | No | |
| Do you have AIDS? | No | |
| Do you have Alzheimer's disease? | No | |
| Have you ever had a tattoo? If yes, what year did you get the tattoo? | No | |
| Have you ever had your body pierced? If yes, where and what year? | Yes | 7 years ago ear |
| Have you had a blood transfusion in the last 12 months? If yes, what was the date of transfusion? | No | |
| Have you ever received pituitary-derived human growth hormone? If yes, what year? | No | |
| Have you ever received factor VIII or Factor IX concentrate? If yes, what year? | No | |
| Family History | ||||
| FAMILY MEMBER | AGE/AGE OF DEATH | HEALTH PROBLEMS | AGE DIAGNOSED | LIVING/DEAD |
| Mother | 59 | receding gums | L | |
| Father | 55 | Healthy | L | |
| Sister(s) | 33 | Healthy | L | |
| Mother's Father | 66 | Stroke | D | |
| Mother's Mother | 68 | Heart failure | D | |
| Mother's Brother(s) | 57 | Healthy | L | |
| Father's Father | 40 | car accident (both killed, in their 40's) | D | |
| Father's Mother | 40 | car accident (both killed, in their 40's) | D | |
| Father's Brother(s) | 56 | Healthy | L | |