Fairfax Cryobank

Donor Sample Medical Profile

Questions

*Personal Behavior History*
Question	Response
Alcohol use: If yes, oz./week and type of alchohol:	Occasionally - 8 oz. beer/week
Do you or any of your relatives have a history of alcoholism or alcohol abuse? 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?	0
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
Any dietary restrictions? If yes, explain:	No

Sexual History

*Have you ever had sex with:*
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
A person having intravenous, intramuscular, or subcutaneous injection of drugs not prescribed by a licensed physician for medical purposes?	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 or any family members 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 - Negative for at least 86 mutations
Have you been tested for Alpha-1 Antitrypsin Disorder? If yes, the result:	No

*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
Fanconi Anemia: If yes, result(s):	N/A
Niemann-Pick: 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
BRCA1/BRCA2 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?	N/A
If yes, result:	N/A
Are you of Mediterranean, Greek or Italian ancestry?	Yes
If yes, have you been tested as a carrier of thalassemia?	Yes - Initial 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	None
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
Autism	None
Autism Spectrum Disorder	None
PDD (pervasive developmental delay)	None
Asperger's Syndrome	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	None
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:	2000: ACL reconstruction for lacrosse injury
Hospitalization other than surgery: Year & type of illness:	None
Have you ever had any broken bones? If yes, please describe:	Yes - Broken ankle from skateboarding, 1996
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:	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:	Multivitamin, taken once per day for general nutrition
List all current medication or treatments (include vitamins, aspirin, antacids, laxatives, herbal, sports supplements, etc.) Include drug, frequency and duration taken, and reason:	Multivitamin, taken once per day for general nutrition
Do you wear glasses or contact lenses? Are you near or far-sighted?	Yes - Near-Sighted
Usual weight?	175
Recent loss or gain? # of lbs and reason:	No
Allergies (medicines, food, pollens)? If yes, please list substance and reaction caused:	No
Have you been exposed to, or been at risk of exposure to: radiation, chemicals, or toxic amounts of lead, mercury, or gold? If yes, please describe:	No
Have you ever had occupational exposure to radiation or chemicals? If yes, please describe:	Yes - Worked in a biomedical research lab, but no carcinogens present
Have you had a fever with headache in the last seven days? If yes, when and why?	No
Have you been permanently excluded or deferred from donating blood or plasma? If yes, when and why?	No
Have you been tested for HIV (AIDS)? If yes, when:	Yes - Negative, ongoing donor screening
Sexual orientation:	Heterosexual
Number of current sexual partners:	1
Has any sexual partner ever been positive for HIV (AIDS)? If yes, describe:	No
Have you had a partner who has had cultures of Trichomonas? 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

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

Health Problem

Healthy

Living / Dead

Living

Your Father

Question

Response

Comment/Age Affected

Current age or age at death

Health Problem

Healthy

Living / Dead

Living

Brother(s)

Your Brother 1

Question

Response

Comment/Age Affected

Current age or age at death

Health Problem

Healthy

Living / Dead

Living

Question

Response

Comment/Age Affected

Current age or age at death

Health Problem

Hip replacement due to past hockey injury

Living / Dead

Living

Question

Response

Comment/Age Affected

Current age or age at death

Health Problem

Healthy

Living / Dead

Living

Question

Response

Comment/Age Affected

Current age or age at death

Health Problem

Healthy

Living / Dead

Living

Question

Response

Comment/Age Affected

Current age or age at death

Health Problem

Healthy

Living / Dead

Living

Question

Response

Comment/Age Affected

Current age or age at death

Health Problem

Healthy

Living / Dead

Living

Question

Response

Comment/Age Affected

Current age or age at death

Health Problem

Lung cancer	74
Cause of death: Lung cancer	77

Living / Dead

Dead

Question

Response

Comment/Age Affected

Current age or age at death

Health Problem

Healthy

Living / Dead

Living

Question

Response

Comment/Age Affected

Current age or age at death

Health Problem

Healthy

Living / Dead

Living

Question

Response

Comment/Age Affected

Current age or age at death

Health Problem

Healthy

Living / Dead

Living

Question

Response

Comment/Age Affected

Current age or age at death

Health Problem

Healthy

Living / Dead

Living