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Personal Behavior History

Question Response
Current alcohol use:
If yes, oz./week and type of alcohol:
Never
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:
No - A little slack on vegetable intake
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 97 mutations tested
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?Yes - Initial donor screen
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 attackNone
Congenital heart diseaseNone
Hemophilia/bleeding problemNone
EmphysemaNone
Cystic FibrosisNone
Alpha-1 Antitrypsin DeficiencyNone
Pyloric stenosisNone
Colon cancerN/A
Inflammatory bowel diseaseNone
Irritable Bowel SyndromeN/A
Diabetes mellitus requiring insulin therapyNone
Diabetes mellitus not requiring insulin therapyGrandparent - Paternal grandfather, age 80
PKU or inherited metabolism disorderNone
Progressive kidney diseaseNone
Polycystic kidney diseaseNone
Miscarriages or stillbornMother - Miscarriage, age 21
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 diseaseGrandparent - Paternal grandmother, age 65
Down SyndromeNone
AutismNone
Autism Spectrum DisorderNone
Pervasive Developmental Delay (PDD)None
Asperger's SyndromeNone
SchizophreniaNone
Bipolar (manic depressive psychosis)None
Attention Deficit Disorder (ADD)N/A
Attention Deficit Hyperactivity Disorder (ADHD)N/A
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 DegenerationN/A
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:
Adenoidectomy at age 12 - Bone at base of finger pinned and nerve stitched together due to accident, 2002
Hospitalization other than surgery:
Age & type of illness:
No
Have you ever had any broken bones?
If yes, please give age and description:
Yes - Finger due to 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:Several Motrin tablets for two weeks for tendonitis in wrist. Occasional Tylenol for a headache.
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?167
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?
No
Have you ever had your ear(s) or body pierced?
If yes, where and what year?
Yes - Ear, age 13

Family Medical History
See list of questions asked here

Question Response Comment/Age Affected
Current age or age at death 47
Health Problem First trimester miscarriage - no hospitalization21
Spondylolisthesis (displacement of a vertebra) - no treatment or surgery required30
Poor gums due to smoking42
Living / DeadLiving
Question Response Comment/Age Affected
Current age or age at death 51
Health Problem Heart murmur28
Living / DeadLiving
Question Response Comment/Age Affected
Current age or age at death 23
Health Problem Healthy 
Living / DeadLiving
Question Response Comment/Age Affected
Current age or age at death 19
Health Problem Frequent ear infections in childhood 
Adenoidectomy (surgical removal of the adenoids)7
Reconstruction of ear drum as teenager 
Living / DeadLiving
Question Response Comment/Age Affected
Current age or age at death 17
Health Problem Healthy 
Living / DeadLiving
Question Response Comment/Age Affected
Current age or age at death 73
Health Problem Healthy73
Living / DeadLiving
Question Response Comment/Age Affected
Current age or age at death 67
Health Problem Asthma since childhood 
Hay fever since childhood 
Breast cancer - metastasized to brain and liver (cause of death)64
Living / DeadDead
Question Response Comment/Age Affected
Current age or age at death 49
Health Problem Healthy 
Living / DeadLiving
Question Response Comment/Age Affected
Current age or age at death 45
Health Problem Healthy 
Living / DeadLiving
Question Response Comment/Age Affected
Current age or age at death 51
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 86
Health Problem Diabetes mellitus, controlled by diet80
Colon cancer, successfully treated81
Living / DeadLiving
Question Response Comment/Age Affected
Current age or age at death 81
Health Problem Parkinson's Disease65
Chronic Obstructive Pulmonary Disease - COPD (cause of death)81
Living / DeadDead
Question Response Comment/Age Affected
Current age or age at death 64
Health Problem Tonsils removed in childhood 
Melanoma - age unknown 
Living / DeadLiving
Question Response Comment/Age Affected
Current age or age at death 60
Health Problem Tonsils removed in childhood 
Hepatitis A2
Living / DeadLiving
Question Response Comment/Age Affected
Current age or age at death 46
Health Problem Healthy 
Living / DeadLiving
Question Response Comment/Age Affected
Current age or age at death 43
Health Problem Mild scoliosis - no treatment necessary4
Stomach ulcers age 9-149
Tonsils removed17
Varicose veins removed in legs33
Hysterectomy38
Living / DeadLiving
Question Response Comment/Age Affected
Current age or age at death 58
Health Problem Asthma since childhood - no inhaler required 
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 49
Health Problem Cause of death - Car accident49
Living / DeadDead