Personal Behavior History

Question Response
Current alcohol use:
If yes, oz./week and type of alcohol:
Regularly - 36 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 at least 97 mutations
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
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?No
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 55
Congenital heart diseaseNone
Hemophilia/bleeding problemNone
EmphysemaNone
Cystic FibrosisNone
Alpha-1 Antitrypsin DeficiencyNone
Pyloric stenosisNone
Colon cancerN/A
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
AcneSelf - age 13; Sister age 12
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:
Rod insertion surgery for broken leg due to automobile accident at age 19; Rod removal surgery on leg at age 20
Hospitalization other than surgery:
Age & type of illness:
None
Have you ever had any broken bones?
If yes, please give age and description:
Yes - Broken leg at age 19 due to automobile 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:
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:None
List all current medication or treatments (include vitamins, aspirin, antacids, laxatives, herbal, sports supplements, etc.) Include drug, frequency and duration taken, and reason:None
Do you wear glasses or contact lenses?
Are you near or far-sighted?
Yes - Near-sighted
Usual weight?164
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?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 Comment/Age Affected
Current age or age at death 56
Health Problem Kidney stones, treated with ultrasound to break up stones40
Living / DeadLiving
Question Response Comment/Age Affected
Current age or age at death 66
Health Problem Hay fever, treated with medication20
High cholesterol, controlled with diet and exercise until age 65; now controlled with medication35
Living / DeadLiving
Question Response Comment/Age Affected
Current age or age at death 22
Health Problem Acne, treated with over-the-counter medication12
Living / DeadLiving
Question Response Comment/Age Affected
Current age or age at death 20
Health Problem Acne, treated with over-the-counter medication12
Hayfever, treated with medication20
Living / DeadLiving
Question Response Comment/Age Affected
Current age or age at death 84
Health Problem Heart attack, treated with medication and diet control55
Pneumonia, no medication or treatment received84
Cause of death: Pneumonia84
Living / DeadDead
Question Response Comment/Age Affected
Current age or age at death 90
Health Problem Stomach cancer, successfully treated with surgery70
Osteoporosis, treated with calcium pills79
Living / DeadLiving
Question Response Comment/Age Affected
Current age or age at death 61
Health Problem Healthy 
Living / DeadLiving
Question Response Comment/Age Affected
Current age or age at death 59
Health Problem Healthy 
Living / DeadLiving
Question Response Comment/Age Affected
Current age or age at death 67
Health Problem Excessive plaque in lungs (job-related), no treatment or medication received66
Cause of death: Dehydration due to excessive plaque in lungs67
Living / DeadDead
Question Response Comment/Age Affected
Current age or age at death 84
Health Problem Breast cancer, successfully treated with surgery and medication79
Alzheimer's Disease, no medication or treatment received83
Cause of death: Alzheimer's Disease84
Living / DeadDead
Question Response Comment/Age Affected
Current age or age at death 68
Health Problem Healthy 
Living / DeadLiving
Question Response Comment/Age Affected
Current age or age at death 63
Health Problem Healthy 
Living / DeadLiving