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Personal Behavior History

Question Response
Current alcohol use:
If yes, oz./week and type of alcohol:
Rarely
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?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?N/A
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?N/A
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 86 mutations
Karyotype?
If yes, the result:
Yes - Normal karyotype
Spinal Muscular Atrophy (SMA)?
If yes, the result:
Unknown - Donor was not tested
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?N/A - N/A
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 attackNo
Congenital heart diseaseNo
Hemophilia/bleeding problemNo
EmphysemaN/A
Cystic FibrosisNo
Alpha-1 Antitrypsin Deficiency
Pyloric stenosisNo
Colon cancerN/A
Inflammatory bowel diseaseNo
Irritable Bowel SyndromeN/A
Diabetes mellitus requiring insulin therapyNo
Diabetes mellitus not requiring insulin therapyNo
PKU or inherited metabolism disorderNo
Progressive kidney diseaseNo
Polycystic kidney diseaseNo
Miscarriages or stillbornNo
Herpes simplex virus, genitalNo
MigrainesNo
Mental retardationNo
Senility or mental deterioration before age 60No
Epilepsy/seizuresNo
Neural tube defects - open spine or hydrocephalus/water on the brainNo
Huntington's diseaseNo
Tuberous sclerosisNo
NeurofibromatosisNo
Parkinson's diseaseNo
Down SyndromeNo
AutismN/A
Autism Spectrum DisorderN/A
Pervasive Developmental Delay (PDD)N/A
Asperger's SyndromeN/A
SchizophreniaNo
Bipolar (manic depressive psychosis)No
Attention Deficit Disorder (ADD)N/A
Attention Deficit Hyperactivity Disorder (ADHD)N/A
Muscular DystrophyNo
Loss of muscle coordinationNo
Rheumatoid ArthritisNo
Reiter's DiseaseNo
Club footNo
Deafness before age of 60No
Cataracts before age of 60No
Blindness in both eyes before age of 60No
GlaucomaNo
Macular DegenerationN/A
AcneN/A
PsoriasisNo
AlbinismNo
More than 5 purple or coffee-colored spots on the skin-1.5 cm (1/2 inch) or largerNo
Drug abuse, misuse, or addictionNo
Cleft palate or cleft lipNo
Serious birth defectsNo
Inguinal herniaNo
Premature degeneration of any organ systemNo
The same cancer in more than one family memberNo

Donor Medical History

Question Response
List any operations:
Age & reason:
None
Hospitalization other than surgery:
Age & type of illness:
N/A
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:
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?
No
Usual weight? 155-160 lbs.
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?
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 57
Health Problem Healthy 
Living / DeadLiving
Question Response Comment/Age Affected
Current age or age at death 60
Health Problem Healthy 
Living / DeadLiving
Question Response Comment/Age Affected
Current age or age at death 69
Health Problem Pneumonia69
Living / DeadDead
Question Response Comment/Age Affected
Current age or age at death 69
Health Problem High blood pressure67
Living / DeadDead
Question Response Comment/Age Affected
Current age or age at death 62
Health Problem Healthy 
Living / DeadLiving
Question Response Comment/Age Affected
Current age or age at death 60
Health Problem Healthy 
Living / DeadLiving
Question Response Comment/Age Affected
Current age or age at death 52
Health Problem Healthy 
Living / DeadLiving
Question Response Comment/Age Affected
Current age or age at death 42
Health Problem Healthy 
Living / DeadLiving
Question Response Comment/Age Affected
Current age or age at death 50
Health Problem Healthy 
Living / DeadLiving
Question Response Comment/Age Affected
Current age or age at death 87
Health Problem Intestinal cancer83
Living / DeadDead
Question Response Comment/Age Affected
Current age or age at death 91
Health Problem Healthy 
Living / DeadLiving
Question Response Comment/Age Affected
Current age or age at death 67
Health Problem Healthy 
Living / DeadLiving
Question Response Comment/Age Affected
Current age or age at death 65
Health Problem Healthy 
Living / DeadLiving
Question Response Comment/Age Affected
Current age or age at death 62
Health Problem Healthy 
Living / DeadLiving
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 55
Health Problem Healthy 
Living / DeadLiving
Question Response Comment/Age Affected
Current age or age at death 52
Health Problem Healthy 
Living / DeadLiving