Fairfax Cryobank |
Donor 2935 Medical Profile |
Questions |
Personal Behavior History |
Donor Genetic History |
Donor Medical History |
Family Medical History |
Personal Behavior History | ||
Question | Response | |
Alcohol use: If yes, oz./week and type of alcohol: | Occasionally - 2oz. liquor or beer/week | |
Do you or any of your relatives have a history of alcoholism or alcohol abuse? 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 | |
How many packs per day? | 0 | |
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 | |
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 | |
Another man anal or oral, even once, since 1977? | No | |
A person having intravenous, intramuscular, or subcutaneous injection of drugs not prescribed by a licensed physician for medical purposes? | No |
Have you: | ||
Question | Response |
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 at least 97 mutations | |
Have you been tested for Alpha-1 Antitrypsin Disorder? If yes, the result: | No | |
Have you had any additional genetic testing? If yes, complete the following: | Yes - Karyotype, SMA, and Tay Sachs | |
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 - Standard donor screening |
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): | N/A | |
Gaucher: If yes, result(s): | N/A | |
Canavan: If yes, result(s): | N/A | |
Fanconi Anemia: If yes, result(s): | N/A | |
Niemann-Pick: 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 | |
BRCA1/BRCA2 If yes, result(s): | N/A |
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 - Standard donor screening | |
Are you of Mediterranean, Greek or Italian ancestry? | No | |
If yes, have you been tested as a carrier of thalassemia? | Yes | |
If yes, result: | Non Carrier - Standard donor screening |
Have you or any member of your family had any of the following conditions? If yes, please list the affected individual(s), mother or father's side, age at onset, treatment and any other pertinant information. | ||
Heart attack | None |
|
Congenital heart disease | None |
|
Hemophilia/bleeding problem | None |
|
Severe bleeding tendency | None |
|
Cystic Fibrosis | None |
|
Alpha-1 Antitrypsin Disorder | None |
|
Pyloric stenosis | None |
|
Inflammatory bowel disease | None |
|
Diabetes mellitus requiring insulin therapy. | None |
|
Diabetes mellitus not requiring insulin therapy. | None |
|
PKU or inherited metabolism disorder | None |
|
Progressive kidney disease | None |
|
Polycystic kidney disease | None |
|
Miscarriages or stillborn | None |
|
Herpes simplex virus, genital | None |
|
Migraines | None |
|
Mental retardation | None |
|
Senility or mental deterioration before age 60 | None |
|
Epilepsy/seizures | None |
|
Neural tube defects - open spine or hypocephalus/water on the brain | None |
|
Huntington's disease | None |
|
Tuberous sclerosis | None |
|
Neurofibromatosis | None |
|
Parkinson's disease | None |
|
Down's syndrome/Mongolism | None |
|
Autism | None |
|
Autism Spectrum Disorder | None |
|
PDD (pervasive developmental delay) | None |
|
Asperger's Syndrome | None |
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Schizophrenia | None |
|
Manic depressive psychosis | None |
|
Muscular dystrophy | None |
|
Loss of muscle coordination | None |
|
Rheumatoid arthritis | None |
|
Reiter's disease | None |
|
Club foot | None |
|
Deafness before age of 60 | None |
|
Cataracts before age of 60 | None |
|
Blindness in both eyes before age of 60 | None |
|
Glaucoma | None |
|
Psoriasis | None |
|
Albinism | None |
|
More than 5 purple or coffee-colored spots on the skin (size of a quarter or larger) | None |
|
Drug abuse, misuse, or addiction | None |
|
Cleft palate or cleft lip | None |
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Serious birth defects | None |
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Inguinal hernia | None |
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Premature degeneration of any organ system | None |
|
The same cancer in more than one family member | None |
Donor Medical History | ||
Question | Response | |
List any operations: Age & reason: | Appendectomy in 1990 due to an inflamed appendix - Wisdom teeth removed in 1999 | |
Hospitalization other than surgery: Age & type of illness: | No | |
Have you ever had any broken bones? If yes, please give age and description: | Yes - Broken hand due to a fall in 1992 | |
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: | 1 - Flu | |
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: | TheraFlu taken approximately twice a year for 2 days as needed for cold/flu; Multi-vitamin taken daily for general health; Ibuprofen taken as needed for general aches, pains, and the occasional headache; Prednisone taken once per day for 10 daysdue to poison ivy. | |
List all current medication or treatments (include vitamins, aspirin, antacids, laxatives, herbal, sports supplements, etc.) Include drug, frequency and duration taken, and reason: | Multi-vitamin taken daily for general health | |
Do you wear glasses or contact lenses? Are you near or far-sighted? | Yes - Near sighted | |
Usual weight? | 182 | |
Recent loss or gain? # of lbs and reason: | No | |
Allergies (medicines, food, pollens)? If yes, please list substance and reaction caused: | No | |
Have you been exposed to, or been at risk of exposure to: radiation, chemicals, or toxic amounts of lead, mercury, or gold? If yes, please describe: | No | |
Have you been permanently excluded or deferred from donating blood or plasma? If yes, when and why? | No | |
Have you been tested for HIV (AIDS)? If yes, when: | Yes - Ongoing donor testing | |
Sexual orientation: | Heterosexual | |
Number of current sexual partners: | 1 | |
Have you had a partner who has had cultures of Trichomonas? If yes, describe: | No | |
Have you ever been convicted of a felony? If yes, please explain: | No | |
Have you ever had a tattoo? If yes, what year did you get the tattoo? | Yes - 1998 | |
Have you ever had your ear(s) or body pierced? If yes, where and what year? | Yes - Ears: 1999 and 2002 | |
Have you ever received pituitary-derived human growth hormone? If yes, what year? | No | |
Have you been diagnosed with hemophilia or a related clotting disorder and received human derived clotting factor concentrates (non-viral inactivated Factor VIII or Factor IX concentrate)? If yes, what year? | No |
Family Medical History |
Complete for each of the following relatives. List all specific health problems, operations, and/or causes of death (include stillborns, infant deaths and childhood deaths) for each individual. |
Your MotherQuestion | Response | Comment/Age Affected | Current age or age at death | 57 | | Health Problem |
Living / Dead | Living | |
|
Your FatherQuestion | Response | Comment/Age Affected | Current age or age at death | 55 | | Health Problem |
Living / Dead | Living | |
|
Sister(s) |
Your Sister 1Question | Response | Comment/Age Affected | Current age or age at death | 25 | | Health Problem |
Living / Dead | Living | |
|
Daughter(s) |
Your Daughter 1Question | Response | Comment/Age Affected | Current age or age at death | 1 | | Health Problem |
Living / Dead | Living | |
|
Your Mother's MotherQuestion | Response | Comment/Age Affected | Current age or age at death | 81 | | Health Problem |
Living / Dead | Living | |
|
Your Mother's Sisters 1Question | Response | Comment/Age Affected | Current age or age at death | 55 | | Health Problem |
Living / Dead | Living | |
|
Your Mother's Brothers 1Question | Response | Comment/Age Affected | Current age or age at death | 51 | | Health Problem |
Living / Dead | Living | |
|
Your Father's FatherQuestion | Response | Comment/Age Affected | Current age or age at death | 78 | | Health Problem |
Living / Dead | Dead | |
|
Your Father's MotherQuestion | Response | Comment/Age Affected | Current age or age at death | 78 | | Health Problem |
Living / Dead | Living | |
|
Your Father's Brothers 1Question | Response | Comment/Age Affected | Current age or age at death | 52 | | Health Problem |
Living / Dead | Living | |
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