DonorChildren

Fairfax Cryobank
Donor 1864 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 alchohol: Occasionally – 0-18 oz. of wine/week
Any relatives with alcoholism?
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? 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
Any dietary restrictions?
If yes, explain: No

Sexual History

Have you ever had sex with:
Question Response
Another man anal or oral, even once, since 1977? No
A person having non-medical intravenous, intramuscular, or subcutaneous injection of drugs not prescribed by a physician for medical purposes since 1977? No
A person having engaged in sex in exchange for money or drugs at any time since 1977? No
A person who has had sex with another person described in any of the above in the preceding 12 months? No

Have you:
Question Response
Have you been exposed to known or suspected HIV-infected blood through percutaneous inoculation or through contact with an open wound, non-intact skin, or mucous membrane within the preceding 12 months? No

Donor Genetic History
Question Response
Were you born with any birth defects?
If yes, explain: No
Are there any known genetic conditions or birth defects in your family? No
Have you been tested for Cystic Fibrosis?
If yes, the result: Yes – Non carrier for at least 86 mutations
Have you been tested for Alpha-1 Antitrypsin Disorder?
If yes, the result: Yes – Not carrier

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

Ancestry
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 thalassemia? Yes – Standard donor screening
If yes, result: Non Carrier

Have you, any member of your family, or any relative had or currently have any of the following conditions? Explain any conditions, indicating which side of the family (maternal/paternal), the age of the family member at the onset of the condition/
problem, and any other pertinent information.
Heart attack
Grandparent – Maternal grandfather age 76; Paternal grandfather age 67 and 75
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
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
Mother – age 17
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
Serious birth defects
None
Inguinal hernia
None
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:
Year & reason: Wisdom teeth extracted – 2001
Hospitalization other than surgery:
Year & type of illness: Hospitalized in 2003 – Food poisoning
Have you ever had any broken bones?
If yes, please describe: Yes – left radius
Have you ever had any serious illnesses?
If yes, please describe: No
How many days in the past 12 months could you not work because of all illness (colds, flu, accidents, surgery, etc)?
Please describe: N/A
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: Multivitamin (daily) Creatine (6 times over the last 4 months)
List all current medication or treatments (include vitamins, aspirin, antacids, laxatives, herbal, sports supplements, etc.) Include drug, frequency and duration taken, and reason: Multivitamin (daily)
Do you wear glasses or contact lenses?
Are you near or far-sighted? No
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 ever had occupational exposure to radiation or chemicals?
If yes, please describe: No
Have you had a fever with headache in the last seven days?
If yes, when and why? No
Have you ever been refused as a blood donor?
If yes, when and why? No
Have you been tested for HIV (AIDS)?
If yes, when: Yes
Sexual orientation: Heterosexual
Number of current sexual partners: 0
Has any sexual partner ever been positive for HIV (AIDS)?
If yes, describe: No
Has any sexual partner had an episode of trichmoniasis?
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? No
Have you ever had your ear(s) or body pierced?
If yes, where and what year? No
Have you had a blood transfusion in the last 12 months?
If yes, what was the date of the transfusion? No
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

Please indicate whether you currently have, have had in the past, or have ever been treated for:
Question Response
Hydrocele No
Syphilis No
Blood transfusion No
Prolonged fever No
Herpes No
Fever above 101 F (in the past 3 months) No
Hepatitis B, C, other No
Orchitis No
Genital Warts/Papillomavirus No
Epididymitis No
Liver disease No
Prostatitis No
Renal disease No
Mumps w/testes involved No
Diabetes No
Urethritis No
Psychiatric disorders No
Varicocele No
Undescended testicle No
AIDS No
Tuberculosis No
Alzheimer’s disease No
Multiple sclerosis No
Creutzfeldt-Jacob disease (CJD or vCJD) No
Note any comments regarding above items: N/A

Indicate conditions occurring now or in the past:
Question Response
rashes, color change No
frequent urinating No
itching No
waking to urinate
# of times / night: No
warts, moles No
cancer No
eczema, lumps, hives No
sores or discharge No
very dry skin No
bleeding or bruising No
excessive sweating No
trouble swallowing No
minor injury Yes – Leg injury (random accident) 4 years ago; struck in eye in 1998 – no issues
poor appetite No
anemia No
gas, cramps, pains Yes
lymph node or gland swelling No
heartburn, indigestion No
ear trouble, infection No
nausea, vomiting, constipation, diarrhea No
blood in stool or black stool No
hearing loss, ringing in ear No
yellow jaudice, hepatitis B or C No
eye problems No
hemorrhoids No
nosebleeds No
hernia No
sore throats Yes – Nothing out of the ordinary as a child
gall bladder problems No
stuffy nose, sinus trouble, hay fever No
pains in joints, arthritis No
high blood pressure No
swollen joints No
hoarseness No
back pain, neck pain No
dental or gum problems No
head injury, concussion No
enlarged or painful breasts No
headaches Yes – Rarely, nothing out of the ordinary
breast lumps No
dizziness, fainting No
discharge from nipples No
convulsions, seizures, fits No
shortness of breath No
shaking, tremor No
cough, chest colds Yes – Nothing out of the ordinary
weakness, paralysis No
bringing up sputum with blood No
numbness, tingling No
wheezing, asthma No
difficulty walking, coordination No
chest pain, pleurisy No
poor circulation, varicose veins No
TB or exposure to TB No
depression, anxiety No
fevers, sweats, chills No
poor sleeping No
pneumonia No
nervousness, tension No
fast or irregular heartbeat No
trouble thinking, remembering No
chest pain, tightness, pressure No
crying, upset, worrying Yes – Rarely, nothing out of the ordinary
trouble breathing when lying down No
sexual problems No
waking short of breath No
goiter, thyroid problems No
swelling of feet or ankles No
blood clots No
previous heart trouble No
murmurs or rheumatic fever Yes – Benign flow murmur, resolved
CMV IgG Antibody Negative
CMV IgM Antibody Negative
Any other comments N/A

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 Mother
Question Response Comment/Age Affected
Current age or age at death 48
Health Problem
Psorasis 17
Hysterectomy 33
Living / Dead Living

Your Father
Question Response Comment/Age Affected
Current age or age at death 43
Health Problem
Work related accident – cause of death 43
Anti-diuretic hormone secretion syndrome 17
Living / Dead Dead

Sister(s)

Your Sister 1
Question Response Comment/Age Affected
Current age or age at death 27
Health Problem
Healthy
Living / Dead Living

Your Mother’s Father
Question Response Comment/Age Affected
Current age or age at death 76
Health Problem
Heart attack 68
Melanoma removed 76
Living / Dead Living

Your Mother’s Mother
Question Response Comment/Age Affected
Current age or age at death 66
Health Problem
Healthy
Living / Dead Living

Your Mother’s Brothers 1
Question Response Comment/Age Affected
Current age or age at death 47
Health Problem
Spleen removed 42
Living / Dead Living

Your Mother’s Brothers 2
Question Response Comment/Age Affected
Current age or age at death 46
Health Problem
Healthy
Living / Dead Living

Your Mother’s Brothers 3
Question Response Comment/Age Affected
Current age or age at death 43
Health Problem
Healthy
Living / Dead Living

Your Father’s Father
Question Response Comment/Age Affected
Current age or age at death 75
Health Problem
Heart attack 67
Sports related knee injury 18
Second heart attack – cause of death 75
Living / Dead Dead

Your Father’s Mother
Question Response Comment/Age Affected
Current age or age at death 75
Health Problem
Healthy
Living / Dead Living

Your Father’s Sisters 1
Question Response Comment/Age Affected
Current age or age at death 55
Health Problem
Hysterectomy 47
Blood clot removed 50
Living / Dead Living

Your Father’s Sisters 2
Question Response
Current age or age at death N/A
Health Problem
N/A N/A
Living / Dead N/A

Your Father’s Brothers 1
Question Response Comment/Age Affected
Current age or age at death 46
Health Problem
Healthy
Living / Dead Living