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Medical Health History Profile

MEDICAL & HEALTH HISTORY PROFILE

As per AABB and International Standards, this form should be signed ‘not more than 7 days before the birth of your baby.
This form provides relevant information such as Educational Materials and Medication List to guide the Client in answering the questionnaire.
The Mother and the Father should answer all questions on this form.
It is important that the Mother signs this form with her full name.

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.

Please fill out this form within seven (7) days of Delivery

Health of the MOTHER and baby’s BIOLOGICAL FATHER

Are you in good general health? if NO, please explain

Yes

Are you suffering from any chronic disease? If YES, please specify

Yes

Are you taking any prescribed medication/s? If YES, please specify name/ reason

Yes

Are you having complications with this pregnancy? If YES, please specify

Yes

Are you having planned cesarean delivery?

Yes

Do you currently have an infectious skin disease? N/A for father

Yes

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)

Yes

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

Yes

Propecia (finasteride) – hair loss treatment within the last month

Yes

Live Vaccines (Measles, Mumps) >> within the last month

Yes

Smallpox Vaccine >> within the past 8 weeks

Yes

Any chemotherapy >> during pregnancy N/A for father

Yes

Immune Globulin (Not Rh Immune Globulin) >> within the past 12 months

Yes

Experimental Medications/Vaccines >> within the past 12 months

Yes

Rabies Vaccine – for exposure >> within the past 12 months

Yes

Soriatane (acitretin) or Tegison (etretinate) – for psoriasis >> within the past 3 years

Yes

Insulin from a Cow Source >> Ever

Yes

Growth Hormone from human Pituitary Glands (not infertility hormones) >> Ever

Yes

Since 1980, have you received a transfusion blood, platelets, plasma, cryoprecipitate or granulocytes in the UK?

Yes

Since 1980, have you spent more than a total of 6 months in Europe? (This includes living or travelling)

Yes

In the past 6 months, have you been bitten by an animal suspected of having rabies?

Yes

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?

Yes

Come into contact with someone else’s blood (E.g., accidental needle stick)

Yes

Had a tattoo, any type of piercings (ear or body), acupuncture or had a needle gun used on you? Circle applicable.

Yes

Received shots, vaccinations, including Rh Immune Globulin?

Yes

Been diagnosed with West Nile Virus?

Yes

Been in jail or prison for more than 72 hours?

Yes

Had sexual contact with: Someone with Hepatitis, Jaundice or HIV?

Yes

Had sexual contact with: Anyone who has Hemophilia or has used clotting factor concentrates?

Yes

Had an accidental needle-stick?

Yes

Have YOU or the baby’s BIOLOGICAL FATHER ever:

Been diagnosed with Sepsis? Or Bacteremia?

Yes

None of the Above

Been diagnosed with, or tested positive for HIV HLTV, Syphilis, Hepatitis B or C?

HIV

HLTV

Syphilis

Hepatitis B

Hepatitis C

None of the above

Been significantly exposed to substances that may be transferred in toxic amounts (Lead, Mercury)?

Yes

Been diagnosed with Tuberculosis, Malaria, Chagas disease or Babesiosis or do you have acute respiratory disease?

Yes

Been diagnosed with any form of Creutzfeldt-Jakob disease (CJD) or other Human Transmissible Spongiform Encephalopathy?

Yes

Had head or brain surgery with a transplant of brain covering (dura mater)?

Yes

Had a transplant or medical procedure involving exposure to organs, tissue or living cells from an animal?

Yes

Been deferred as blood donor for a reason other than anemia or being underweight?

Yes

Taken intravenous drugs not prescribed by a physician or had sexual contact with someone who has?

Yes

Since 1977, have you lived in Africa or had sexual contact with anyone who was born or lived in Africa?

Yes

In the past 12 weeks, had contact with someone who had a small pox vaccination?

Yes

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)

Yes

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.)

Yes

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.)

Yes

Have you ever had babesiosis?

Yes

Have you ever been in Africa?

Yes

At any time during the pregnancy has the mother:

Had a medical diagnosis of a Zika virus infection

Yes

Lived in or traveled to an area with an increased risk for Zika virus transmission? (Review the list of ZIKA virus areas of transmission)

Yes

Has anyone been diagnosed in your Maternal or Paternal Family:

Aplastic Anemia

Fanconi Anemia

Thalassemia (Major or Minor)

Chronic Granulomatosis Disease (CGD)

Sickle Cell Anemia (Disease or Trait)

Hunter Syndrome, Hurler Syndrome or any other storage disorder

Severe combined Immunodeficiency Syndrome or Blood/Bleeding and Genetic disorders

Had Creutzfeldt-Jakob Disease (CJD)

Yes

Has the mother traveled outside of UAE in the past 6 months? If yes, please mention when and where.

Yes

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:

Date:

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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July 17, 2023 9:59 am +04

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