QUESTION. Personal Behavior History. Donor Genetic History. Donor Medical History. Family Medical History PERSONAL BEHAVIOR HISTORY. Never N/A.
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1 Donor 4576 Medical Profile S Personal Behavior History Donor Genetic History Donor Medical History Family Medical History PERSONAL BEHAVIOR HISTORY Current alcohol use: If yes, oz./week and type of alcohol: Do you or any of your relatives have a history of alcoholism or alcohol abuse? If yes, relation and age affected: Tobacco use: Do you smoke? If yes, #/day and for how long: If you did smoke but quit, when did you last smoke? Never For how many years? 0 Do you sleep well? Do you exercise on regular basis? Is your diet well balanced? If no, explain: Are you a vegetarian? Any dietary restrictions? If yes, explain: Yes Yes Yes SEXUAL HISTORY HAVE YOU EVER HAD SEX WITH: A partner whose sexual background you are
2 unsure of in the past 12 months? Another man anal or oral, even once, since 1977? DONOR GENETIC HISTORY Were you or any family members born with any birth defects? If yes, explain: Have you been tested for Cystic Fibrosis? If yes, the result: Karyotype? If yes, the result: Spinal Muscular Atrophy (SMA)? If yes, the result: Tay Sachs? If yes, the result: Yes n carrier for at least 97 mutations Yes rmal karyotype n Carrier Standard donor screening n Carrier Standard donor screening ANCESTRY Are you of Jewish ancestry? If yes, please note: Ashkenazi, Sephardi, or Other IF YOU ARE OF JEWISH ANCESTRY, HAVE YOU BEEN TESTED AS A CARRIER OF ANY OF THE FOLLOWING DISEASES? Tay Sachs: Gaucher: Canavan: Fanconi Anemia Type C: Niemann Pick Type A: Bloom Syndrome Familial Dysautonomia Mucolipidosis IV
3 Maple Syrup Urine Disease 1B Usher Syndrome III & 1F Glycogen Storage Disease 1A ABCC8 Related Hyperinsulinism BRCA1/BRCA2 Lipoamide Dehydrogenase Deficiency ANCESTRY Are you of African ancestry? If yes, have you been tested as a carrier of sickle cell anemia or hemoglobin C? If yes, result: Are you of Mediterranean, Greek or Italian ancestry? If yes, have you been tested as a carrier of beta thalassemia? If yes, result: Yes Standard donor screening n Carrier Yes Standard donor screening n Carrier HAVE YOU OR ANY MEMBER OF YOUR FAMILY HAD, CURRENTLY HAVE OR BEEN DIAGNOSED WITH 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 PERTINENT INFORMATION. Heart attack Congenital heart disease Hemophilia/bleeding problem Emphysema Cystic Fibrosis Alpha 1 Antitrypsin Deficiency Pyloric stenosis Colon cancer Inflammatory bowel disease Irritable Bowel Syndrome Diabetes mellitus requiring insulin therapy
4 Diabetes mellitus not requiring insulin therapy PKU or inherited metabolism disorder Progressive kidney disease Polycystic kidney disease Miscarriages or stillborn Herpes simplex virus, genital Migraines Mental retardation Senility or mental deterioration before age 60 Epilepsy/seizures Neural tube defects open spine or hydrocephalus/water on the brain Huntington's disease Tuberous sclerosis Neurofibromatosis Parkinson's disease Down Syndrome Autism Autism Spectrum Disorder Pervasive Developmental Delay (PDD) Asperger's Syndrome Schizophrenia Bipolar (manic depressive psychosis) Attention Deficit Disorder (ADD) Attention Deficit Hyperactivity Disorder (ADHD) Muscular Dystrophy Loss of muscle coordination Rheumatoid Arthritis Reiter's Disease Club foot Deafness before age of 60 Cataracts before age of 60 Blindness in both eyes before age of 60 Glaucoma Macular Degeneration Acne
5 Psoriasis Albinism More than 5 purple or coffee colored spots on the skin 1.5 cm (1/2 inch) or larger Drug abuse, misuse, or addiction Cleft palate or cleft lip Serious birth defects Inguinal hernia Premature degeneration of any organ system The same cancer in more than one family member DONOR MEDICAL HISTORY List any operations: Age & reason: Hospitalization other than surgery: Age & type of illness: Wisdom teeth extraction surgery, age 19 Have you ever had any broken bones? If yes, please give age and description: Have you ever had any serious illnesses? If yes, please give age and description: 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: 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: List all current medication or treatments (include vitamins, aspirin, antacids, laxatives, herbal, sports supplements, etc.) Include drug, frequency and duration taken, and reason: Do you wear glasses or contact lenses? Are you near or far sighted? Yes Two knuckles on right hand, age 15, injured in a fight 0 Ibuprofen taken occasionally for mild headache Usual weight? 207 Recent loss or gain? # of lbs and reason: Allergies (medicines, food, pollens)?
6 If yes, please list substance and reaction caused: Have you been tested for HIV (AIDS)? If yes, when: Yes Negative, ongoing donor screening Sexual orientation: Number of current sexual partners: 1 Have you ever had a tattoo? If yes, what year did you get the tattoo? Have you ever had your ear(s) or body pierced? If yes, where and what year? Heterosexual FAMILY MEDICAL HISTORY YOUR MOTHER Current age or age at death 55 YOUR FATHER Current age or age at death 57 BROTHERS Your Brother 1 Current age or age at death 24 SISTERS Your Sister 1 Current age or age at death 31
7 YOUR MOTHER'S FATHER Current age or age at death 78 YOUR MOTHER'S MOTHER Current age or age at death 77 YOUR MOTHER'S SISTERS 1 Current age or age at death 51 YOUR MOTHER'S SISTERS 2 Current age or age at death 49 YOUR MOTHER'S BROTHERS 1 Current age or age at death 53 YOUR FATHER'S FATHER Current age or age at death 79 YOUR FATHER'S MOTHER
8 Current age or age at death 78 Health Problem Heart failure, no treatment 78 Cause of death: Heart failure 78 Dead YOUR FATHER'S SISTERS 1 Current age or age at death 59 YOUR FATHER'S SISTERS 2 Current age or age at death 55 YOUR FATHER'S BROTHERS 1 Current age or age at death 48
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