Medical Health History Profile
MEDICAL & HEALTH HISTORY PROFILE
Mother's Last Name:
Mother's First Name:
Mother's Mobile Number:
DONOR EDUCATIONAL MATERIALS / MEDICATION LIST
Have you ever taken any of these medications?
HEPATITIS B IMMUNE GLOBULIN – Given the following is exposure to Hepatitis B.
*NOTE: This is different from the Hepatitis B Vaccine, which is a series of 3 injections given over a 6 month period to prevent future infection from exposure to Hepatitis B.
Hepatitis B Immune Globulin (HBIG) is an injected material used to prevent Infection following exposure to Hepatitis B. HBIG does not prevent Hepatitis B infection in every case, therefore potential donors who have taken Hepatitis B Immune Globulin should be evaluated by the Medical Director to be sure they were not infected. Hepatitis B can be transmitted through transfusion and transplants, to be a patient.
UNLICENSED VACCINE – Usually associated with a research protocol, Unlicensed Vaccine is usually associated with a research protocol and the effect with regard to stem cell recipients is unknown. Potential donors who have taken unlicensed vaccines should be evaluated by the Medical Director.
INSULIN FROM COWS (Bovine, or Beef, Insulin) – Used to treat diabetes, Insulin from Cows (Bovine, or Beef, Insulin) is an injected material used to treat diabetes. If this insulin was imported from countries in which “Mad Cow Disease” has been found, it could contain material from infected cattle. There is concern that “Mad Cow Disease” is transmitted by transfusions and transplants. Potential donors who have taken Insulin from cows should be evaluated by the Medical Director.
GROWTH HORMONES FROM PITUITARY GLANDS – Used usually for children with delayed or impaired growth. Growth Hormone from Pituitary Gland was prescribed for children with delayed or impaired growth. The hormone was obtained from pituitary glands, which are found in the brain. Some people who took this hormone developed a rare nervous system condition called Creutzfeldt - Jakob disease (CJD). Potential donors who have taken growth hormone from human pituitary glands should be evaluated by the Medical Director.
PLEASE READ THIS INFORMATION BEFORE YOU COMPLETE THE QUESTIONNAIRE!
ACCURACY AND HONESTY ARE ESSENTIAL
Your complete honesty in answering all questions is very important for the safety of patients who receive your stem cells. All information you provide is confidential
DONOR ELIGIBILITY – SPECIFIC INFORMATION (why we ask about sexual contact)
Sexual contact may cause contagious diseases like HIV to get into the bloodstream and be spread through transfusions or transplants to someone else.
HIV/AIDS Risk Behavior and Symptoms
AIDS is caused by HIV. HIV is spread mainly through sexual contact with an infected person or by sharing needles or syringes used for injecting drugs.
Inform the staff if YOU
Have AIDS or have ever had a positive HIV test
Have used needles to take drugs, steroids, or anything not prescribed by your doctor in the past 5 years
Have had sexual contact in the past 12 months with anyone described above
Have had syphilis or gonorrhea in the past 12 months
In the past 12 months have been in juvenile detention, lockup, jail, or prison for more than 72 hours
Have any of the following conditions that can be signs or symptoms of HIV/AIDS
*** Unexplained weight loss or night sweats
*** Blue or purple spots in your mouth or skin
*** Swollen lymph nodes for more than one month
*** White spots or unusual sores in your mouth
*** Cough that won’t go away or shortness of breath
*** Diarrhea that won’t go away
*** Fever of more than 38 degrees Celsius for more than 10 days
Remember that you CAN give HIV to someone else even if you feel well and have a negative HIV test. This is because tests cannot detect infections for a period of time after a person is exposed to HIV.
Health of the MOTHER and baby’s BIOLOGICAL FATHER
Are you in good general health? if NO, please explain
Are you suffering from any chronic disease? If YES, please specify
Are you taking any prescribed medication/s? If YES, please specify name/ reason
Are you having complications with this pregnancy? If YES, please specify
Are you having planned cesarean delivery?
Do you currently have an infectious skin disease? N/A for father
Do you currently have any medical condition that could be affected adversely by the collection procedure? (E.g.: Cancer, Diabetes, Blood Disease, Bleeding Problems, Lung Disease, Heart Disease, Chest Pain, Stroke, Seizure or Multiple Sclerosis)
Have you taken any of the following Medications/Vaccines within the specified timeframe?
Accutane (isotretinoin) or Proscar for your skin – acne medication >> within the last month
Propecia (finasteride) – hair loss treatment within the last month
Live Vaccines (Measles, Mumps) >> within the last month
Smallpox Vaccine >> within the past 8 weeks
Any chemotherapy >> during pregnancy N/A for father
Immune Globulin (Not Rh Immune Globulin) >> within the past 12 months
Experimental Medications/Vaccines >> within the past 12 months
Rabies Vaccine – for exposure >> within the past 12 months
Soriatane (acitretin) or Tegison (etretinate) – for psoriasis >> within the past 3 years
Insulin from a Cow Source >> Ever
Growth Hormone from human Pituitary Glands (not infertility hormones) >> Ever
Since 1980, have you received a transfusion blood, platelets, plasma, cryoprecipitate or granulocytes in the UK?
Since 1980, have you spent more than a total of 6 months in Europe? (This includes living or travelling)
In the past 6 months, have you been bitten by an animal suspected of having rabies?
In the past 12 months, have YOU or the baby’s BIOLOGICAL FATHER:
Received blood or blood factor products, derivatives or a tissue organ transplant?
Come into contact with someone else’s blood (E.g., accidental needle stick)
Had a tattoo, any type of piercings (ear or body), acupuncture or had a needle gun used on you? Circle applicable.
Received shots, vaccinations, including Rh Immune Globulin?
Been diagnosed with West Nile Virus?
Been in jail or prison for more than 72 hours?
Had sexual contact with: Someone with Hepatitis, Jaundice or HIV?
Had sexual contact with: Anyone who has Hemophilia or has used clotting factor concentrates?
Had an accidental needle-stick?
Have YOU or the baby’s BIOLOGICAL FATHER ever:
Been diagnosed with Sepsis? Or Bacteremia?
Been diagnosed with, or tested positive for HIV HLTV, Syphilis, Hepatitis B or C?
Been significantly exposed to substances that may be transferred in toxic amounts (Lead, Mercury)?
Been diagnosed with Tuberculosis, Malaria, Chagas disease or Babesiosis or do you have acute respiratory disease?
Been diagnosed with any form of Creutzfeldt-Jakob disease (CJD) or other Human Transmissible Spongiform Encephalopathy?
Had head or brain surgery with a transplant of brain covering (dura mater)?
Had a transplant or medical procedure involving exposure to organs, tissue or living cells from an animal?
Been deferred as blood donor for a reason other than anemia or being underweight?
Taken intravenous drugs not prescribed by a physician or had sexual contact with someone who has?
Since 1977, have you lived in Africa or had sexual contact with anyone who was born or lived in Africa?
In the past 12 weeks, had contact with someone who had a small pox vaccination?
From 1980 through 1996, Did you spend time that adds up to three (3) months or more in the United Kingdom? (Review list of countries in the UK)
From 1980 to present did you spend time that adds up to five (5) years or more in Europe? (Review list of countries in Europe.)
From 1980 to present did you Receive a transfusion of blood or blood components in the United Kingdom or France? (Review list of countries in the UK.)
Have you ever had babesiosis?
Have you ever been in Africa?
At any time during the pregnancy has the mother:
Had a medical diagnosis of a Zika virus infection
Lived in or traveled to an area with an increased risk for Zika virus transmission? (Review the list of ZIKA virus areas of transmission)
Has anyone been diagnosed in your Maternal or Paternal Family:
Had Creutzfeldt-Jakob Disease (CJD)
Has the mother traveled outside of UAE in the past 6 months? If yes, please mention when and where.
MEDICAL DIRECTOR (for CELLSAVE Use only)Is the donor eligible according to defined risk-based clinical criteria?
MHHP updated (if obtained more than 7 days before CB collection)?
Medical Director Signature:
Acknowledgment of Medical and Health History Profile
I have completed the Medical and Health History Profile in this Section C. I certify that all the information I have provided to Cellsave is true and correct to the best of my knowledge.
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Document Name: Medical Health History Profile
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