Personal Behavior History

Question Response
Current alcohol use:
If yes, oz./week and type of alcohol:
Occasionally - 12 oz. beer/week
Have you or any of your family members been diagnosed with alcoholism or drug addiction?
If yes, relation and age affected:
No
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?0
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
Another man anal or oral, even once, since 1977?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 for the 99 mutations tested
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:
Unknown - Donor was not tested
Question Response
Are you of Jewish ancestry?
If yes, please note: Ashkenazi, Sephardi, or Other
No
Question Response
Tay Sachs:
If yes, result(s):
N/A
Gaucher:
If yes, result(s):
N/A
Canavan:
If yes, result(s):
N/A
Fanconi Anemia Type C:
If yes, result(s):
N/A
Niemann-Pick Type A:
If yes, result(s):
N/A
Bloom Syndrome:
If yes, result(s):
N/A
Familial Dysautonomia:
If yes, result(s):
N/A
Mucolipidosis IV:
If yes, result(s):
N/A
Maple Syrup Urine Disease 1B:
If yes, result(s):
N/A
Usher Syndrome III & 1F:
If yes, result(s):
N/A
Glycogen Storage Disease 1A:
If yes, result(s):
N/A
ABCC8-Related Hyperinsulinism:
If yes, result(s):
N/A
BRCA1/BRCA2:
If yes, result(s):
N/A
Lipoamide Dehydrogenase Deficiency:
If yes, result(s):
N/A
Question Response
Are you of African ancestry?No
If yes, have you been tested as a carrier of sickle cell anemia?Yes - Standard donor screening
If yes, result:Non Carrier
Are you of Mediterranean, Greek or Italian ancestry?Yes
If yes, have you been tested as a carrier of beta thalassemia?Yes - Standard donor screening
If yes, result:Non Carrier
Heart attackGrandparent - Maternal grandfather, age 89, fatal, no treatment
Congenital heart diseaseNone
Hemophilia/bleeding problemNone
EmphysemaNone
Cystic FibrosisNone
Alpha-1 Antitrypsin DeficiencyNone
Pyloric stenosisNone
Colon cancerNone
Inflammatory bowel diseaseNone
Irritable Bowel SyndromeNone
Diabetes mellitus requiring insulin therapyNone
Diabetes mellitus not requiring insulin therapyNone
PKU or inherited metabolism disorderNone
Progressive kidney diseaseNone
Polycystic kidney diseaseNone
Miscarriages or stillbornNone
Herpes simplex virus, genitalNone
MigrainesNone
Mental retardationNone
Senility or mental deterioration before age 60None
Epilepsy/seizuresNone
Neural tube defects - open spine or hydrocephalus/water on the brainNone
Huntington's diseaseNone
Tuberous sclerosisNone
NeurofibromatosisNone
Parkinson's diseaseNone
Down SyndromeNone
AutismNone
Autism Spectrum DisorderNone
Pervasive Developmental Delay (PDD)None
Asperger's SyndromeNone
SchizophreniaNone
Bipolar (manic depressive psychosis)None
Attention Deficit Disorder (ADD)None
Attention Deficit Hyperactivity Disorder (ADHD)None
Muscular DystrophyNone
Loss of muscle coordinationNone
Rheumatoid ArthritisNone
Reiter's DiseaseNone
Club footNone
Deafness before age of 60None
Cataracts before age of 60None
Blindness in both eyes before age of 60None
GlaucomaNone
Macular DegenerationNone
AcneNone
PsoriasisNone
AlbinismNone
More than 5 purple or coffee-colored spots on the skin-1.5 cm (1/2 inch) or largerNone
Drug abuse, misuse, or addictionNone
Cleft palate or cleft lipNone
Serious birth defectsNone
Inguinal herniaNone
Premature degeneration of any organ systemNone
The same cancer in more than one family memberNone

Donor Medical History

Question Response
List any operations:
Age & reason:
Wisdom tooth extraction this year
Hospitalization other than surgery:
Age & type of illness:
None
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:Multivitamin, Glucosamine, both taken daily for general health; Tylenol, taken for occasional headache
List all current medication or treatments (include vitamins, aspirin, antacids, laxatives, herbal, sports supplements, etc.) Include drug, frequency and duration taken, and reason:Multivitamin, Glucosamine, both taken daily for general health
Do you wear glasses or contact lenses?
Are you near or far-sighted?
No - (Near-sighted before laser surgery)
Usual weight?180
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
Sexual orientation:Heterosexual
How many sexual partners do you currently have?1
Have you ever had a tattoo?
If yes, what year did you get the tattoo?
Yes - 1997
Have you ever had your ear(s) or body pierced?
If yes, where and what year?
Yes - Ear, 1997

Family Medical History
See list of questions asked here

Question Response Comment/Age Affected
Current age or age at death 57
Health Problem Healthy 
Living / DeadLiving
Question Response Comment/Age Affected
Current age or age at death 58
Health Problem Healthy 
Living / DeadLiving
Question Response Comment/Age Affected
Current age or age at death 29
Health Problem Healthy 
Living / DeadLiving
Question Response Comment/Age Affected
Current age or age at death 89
Health Problem Heart attack, fatal, no treatment89
Cause of death: Heart attack89
Living / DeadDead
Question Response Comment/Age Affected
Current age or age at death 86
Health Problem Healthy 
Living / DeadLiving
Question Response Comment/Age Affected
Current age or age at death 55
Health Problem Healthy 
Living / DeadLiving
Question Response Comment/Age Affected
Current age or age at death 53
Health Problem Healthy 
Living / DeadLiving
Question Response Comment/Age Affected
Current age or age at death 56
Health Problem Healthy 
Living / DeadLiving
Question Response Comment/Age Affected
Current age or age at death 87
Health Problem Prostate cancer, no treatment83
Chronic Obstructive Pulmonary Disease (COPD), treated with inhaler84
Cause of death: COPD87
Living / DeadDead
Question Response Comment/Age Affected
Current age or age at death 83
Health Problem Healthy 
Living / DeadLiving
Question Response Comment/Age Affected
Current age or age at death 54
Health Problem Healthy 
Living / DeadLiving
Question Response Comment/Age Affected
Current age or age at death 55
Health Problem Healthy 
Living / DeadLiving
Question Response Comment/Age Affected
Current age or age at death 53
Health Problem Healthy 
Living / DeadLiving
Question Response Comment/Age Affected
Current age or age at death 51
Health Problem Healthy 
Living / DeadLiving