CORD BLOOD DONATION GUIDE - IHealthSpot Interactive

HEALTH HISTORY QUESTIONNAIREPlease call 315-492-2600 or 855-492-2600 if you have any questions or need assistance filling out this form.INSTRUCTIONS: Read each question carefully and answer truthfully or to the best of your knowledge.Mark each response clearly in the box labeled “YES” or “NO.”There are some questions that may require additional information that should be included in the spaceprovided.This form must be completed ONLY by the mother and biological father (if available). Friends or other familymembers may not complete this form.To complete the form, the mother must include her initials and date of birth in the space provided at the bottomof EACH page and on the signature page at the back of the questionnaire.If information on the biological father or the baby’s other relatives does not apply or is unattainable, pleaseleave columns blank.To ensure the most up-to-date information, this form must be completed and signed LESS than 30 days beforeyour delivery due date.WHAT YOU NEED TO KNOW BEFORE ANSWERING: This Health History Questionnaire has questions that are similar to those asked when someone donates blood.You may find some questions to be of a personal nature. This information remains confidential but is needed toassess the safety of donated cord blood.The NYS Department of Health requires that we obtain the health history of the biological father, unless thisinformation is unavailable.Mother1. Were you adopted at early childhood?Yes Yes If YES, is a medical history available for you?MotherEthnicity: Hispanic Non-HispanicRace: White American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander OtherNo No BiologicalFatherYes No Yes No Biological FatherEthnicity: Hispanic Non-HispanicRace: White American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander OtherF91226 Health History QuestionnaireRev. 12/26/18; Reviewed 12/26/18Maternal Initials:Maternal DOB (mm/dd/yyyy)://Page1

MotherMATERNAL HEALTH2. Did this pregnancy use either a donor egg or donor sperm?If YES, is a medical history questionnaire available for the egg or sperm donor?3. Have you ever donated or attempted to donate cord blood using your current, or a different name, to the UpstateCord Blood Bank?If YES, delivery date:4. Have you, for any reason, been told not to donate or been deferred/refused as a blood or cord blood donor?If YES, why?5. Are you and the baby’s father related, except by marriage? (e.g., first cousins)6. Are you currently taking any medication(s)/antibiotic(s) for an infection?If YES, what medication and for which infection?Medication: Infection:Medication: Infection:Medication: Infection:7. Have you had an abnormal result from a prenatal test (e.g., amniocentesis, blood test, ultrasound)?If YES, answer a-c. If NO, skip to next question.a. Which test was abnormal?b. What was the abnormal test result?c. List any diagnoses made (if any) :8. Have you had any children who died within the first 10 years of life?If YES, specify cause:9. Have you ever had a baby die during pregnancy past the 5th month ( 20 weeks)?If YES, specify cause:10. In the past 12 weeks, have you had any shots or vaccinations, other than Tdap, Flu, or RhoGAM?If YES, describe:11. In the past 12 weeks, have you had physical contact with someone who has received the smallpox vaccine?(Examples of contact include: intimacy, touching the vaccination site or bandage covering the vaccination site,or handling laundry that had been in contact with an unbandaged vaccination site.)12. In the past 4 months, have you experienced two (2) or more of the following symptoms:a fever ( 100.5 F or 38.06 C), headache, muscle weakness, skin rash on trunk of the body,or swollen lymph glands?If YES, specify which symptoms and when.Symptom: Date:Symptom: Date:Symptom: Date:Yes Yes Yes No No No Yes Yes Yes No No No Yes No Yes Yes Yes Yes No No No No Yes No F91226 Health History QuestionnaireRev. 12/26/18; Reviewed 12/26/18Maternal Initials:Maternal DOB (mm/dd/yyyy)://Page2

CHART A: Countries considered to be at risk for transmission of variant Cruetzfeldt-Jakob Disease riaCroatiaCzech eland (Republic s (Holland)NorwayPolandPortugalRomaniaSlovak RepublicSloveniaSpainSwedenSwitzerlandUnited Kingdom, whichincludes: England,Northern Ireland,Scotland, Wales,The Isle of Man,The ChannelIslands, Gibraltar andThe Falkland IslandsTRAVEL – REFER TO CHART A TO ANSWER QUESTIONS 13-19Yugoslavia (FederalRepublic of), whichincludes: Kosovo,Montenegro andSerbiaMother13. Since 1980, have you lived in or traveled to any country considered to be at risk for transmission ofvCJD?If YES, answer questions 14 and 15. If NO, go to question 16.14. From 1980 through 1996, did you spend time that adds up to 3 months or more in the UnitedKingdom?Yes No BiologicalFatherYes No Yes No Yes No 15. Since 1980, have you received a transfusion of blood or blood components while in the UnitedKingdom or France?16. Since 1980, have you spent time that adds up to 5 years or more (including time spent in the UnitedKingdom between 1980 and 1996) in any country considered to be at risk for transmission of vCJD?Yes Yes No No Yes Yes No No 17. From 1980 through 1996, were you a member of the U.S. military, a civilian military employee, or adependent of U.S. military member or civilian military employee?18. From 1980 through 1990, did you spend a total of 6 months or more associated with a military basein any of the following countries: United Kingdom, Belgium, Netherlands, or Germany?19. From 1980 through 1996, did you spend a total of 6 months or more associated with a military basein any of the following countries: Spain, Portugal, Turkey, Italy, or Greece?Yes Yes Yes No No No Yes Yes Yes No No No CHART B: Countries considered to be at risk for transmission for HIV-1 Group OBeninCameroonCentral African RepublicChadCongoEquatorial L – REFER TO CHART B TO ANSWER QUESTIONS 20-22Mother20. Since 1977, were you born in, have you lived for longer than one year in, or have you traveled to anyAfrican country considered to be at risk for transmission of HIV-1 group O?If YES, answer question 21. If NO, go to question 22.21. While in one of the African countries listed in the chart, did you receive a blood transfusion or anyother medical treatment with a product made from blood?22. Have you had sexual contact with anyone who was born in or lived in any African country listed in thechart since 1977?Yes No BiologicalFatherYes No Yes Yes No No Yes Yes Maternal Initials:Maternal DOB (mm/dd/yyyy)://F91226 Health History QuestionnaireRev. 12/19/18; Reviewed 12/19/18No No Page3

For up-to-date Zika travel information, including areas with risk of Zika, please visit the Centers ofDisease Control and Prevention at AVEL - ZIKA VIRUS (Refer to web page above for more information on Zika virus transmission)At any point, during your pregnancy:23. Have you had a medical diagnosis of a Zika virus Infection?24. Have you lived or traveled to an area with increased risk for Zika virus transmission? (See website for regions)25. Have you had sexual contact with a person, who in the 6 months prior to sexual contact, has had the Zika virusInfection or lived in or traveled to an area with increased risk for Zika virus transmission?Yes MATERNAL AND PATERNAL HEALTH HISTORYMother26. In the last 5 years, have you had any of the following:a. Blue or purple spots on/under the skin or mucous membranes typical of Kaposi's sarcoma?b. Unexplained weight loss?c. Unexplained persistent diarrhea?d. Unexplained cough and shortness of breath?e. Unexplained temperature higher than 100.5 F (38.06 C) or night sweats for more than 10days?f.Unexplained persistent white spots or sores in the mouth?g. Multiple lumps in your neck, armpits, or groin lasting more than one month?27. Have you ever used a needle, even once, to take drugs, steroids, or anything else not prescribed foryou by a doctor?28. Have you ever tested positive for Hepatitis, HIV/AIDS, Human T-cell Lymphotropic Virus (HTLV) orhad unexplained paraparesis (partial paralysis affecting the lower limbs)?29. Have you ever given or received money or drugs from anyone to engage in sex with you?30. Have you ever engaged in sex with anyone who had taken money or drugs for sex?31. Have you taken any of the following medications? Check all that apply:a. Insulin from cows (bovine or beef insulin) since 1980?b. Growth hormone from human pituitary glands?32. Have you ever had malaria?If YES, specify when:33. In the past 3 years, have you been outside the United States or Canada?If YES, specify where, date, and duration.Where: Date: Duration:Where: Date: Duration:Where: Date: Duration:No Yes No BiologicalFatherYes No Yes Yes Yes Yes Yes No No No No No Yes Yes Yes Yes Yes No No No No No Yes No Yes No Yes No Yes No \Maternal Initials:Maternal DOB (mm/dd/yyyy)://F91226 Health History QuestionnaireRev. 12/19/18; Reviewed 12/19/18Page4

Maternal and Paternal Health History continuedMotherIN THE LAST 12 MONTHS:34. Have you been diagnosed with West Nile Virus or had a positive test for West Nile virus?35. Have you had a tattoo or body piercing?If YES, please answer a. If NO, go to the next question.a. Were shared or non-sterile inks, needles, instruments, or procedures used for the tattoo or piercing?36. Have you had an accidental needle stick or come into contact with someone else's blood through anopen wound (cut or sore), non-intact skin, or mucous membrane (eye or mouth)?37. Have you had or been treated for a sexually transmitted disease including syphilis?38. Have you had sexual contact or lived with a person who has active/ chronic viral hepatitis or yellowjaundice?39. Have you had sex with anyone who has ever used a needle to take drugs, steroids, or anything elsenot prescribed by a doctor?40. Have you had sex with a male who has ever had sex with another male?41. Have you had sex with anyone who has ever tested positive for HIV/AIDS42. Have you been in juvenile detention, lockup, jail, or prison for more than 72 continuous hours?FAMILY HEALTH HISTORYMother43. Have you ever had a blood transfusion or required anychronic blood transfusions?If YES, specify when:44. Have you ever had any type of cancer?If YES, specify all that apply in a-i.If NO, go to next questiona. Brain or other nervous system cancerb. Bone or joint cancerc. Kidney (including renal pelvic) cancerd. Thyroid cancere. Hodgkin's/ Non-Hodgkin's lymphomaf. Acute or chronic myelogenous/myeloid leukemiag. Acute or chronic lymphocytic/lymphoblastic leukemiah. Skin canceri. Other cancer or leukemia:Specify Type:BiologicalFatherBaby’sSiblingsYes Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No No No Mother’sSiblingsBiologicalFatherYes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No Yes No Yes No Baby’sGrandparentsYes No Father’sSiblingsYes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Maternal Initials:Maternal DOB (mm/dd/yyyy)://F91226 Health History QuestionnaireNo No No No No No No No No No Rev. 12/19/18; Reviewed 12/19/18Page5

Family Health History ContinuedMother45. Have you ever been diagnosed with a red blood celldisease?If YES, specify all that apply in a-c.If NO, go to the next question.a. Diamond-Blackfan Syndromeb. Elliptocytosis or Spherocytosisc. G6PD or other red cell enzyme deficiency46. Have you ever been diagnosed with a white blood celldisease?If YES, specify all that apply in a-d.If NO, go to the next question.a. Chronic Granulomatous Diseaseb. Kostmann Syndromec. Shwachman-Diamond Syndromed. Leukocyte Adhesion Deficiency (LAD)47. Have you ever been diagnosed with any Immunedeficiencies?If YES, specify all that apply in a-h.If NO, go to the next question.a. ADA or PNP Deficiencyb. Combined Immunodeficiency Syndrome orCommon Variable Immunodeficiency Diseasec. DiGeorge Syndromed. Hereditary Hemophagocytic Lymphohistiocytosis(HLH)e. Hypoglobulinemiaf. Nezelof Syndromeg. Severe Combined Immunodeficiency (SCID)h. Wiskott-Aldrich Syndrome48. Have you ever been diagnosed with a platelet disease?If YES, specify all that apply in a-f.If NO, go to the next question.a. Amegakaryocytic or HereditaryThrombocytopeniab. Glanzmann Thrombastheniac. Platelet Storage Pool Diseased. Thrombocytopenia with absent radii (TAR)e. Ataxia-Telangiectasiaf. Fanconi or Hemolytic AnemiaBiologicalFatherBaby’sSiblingsYes No Yes No Yes No Baby’sGrandparentsYes No Mother’sSiblingsFather’sSiblings Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Maternal Initials:Maternal DOB (mm/dd/yyyy)://F91226 Health History QuestionnaireRev. 12/19/18; Reviewed 12/19/18Page6

Family Health History y’sGrandparentsYes No Mother’sSiblingsFather’sSiblingsYes No Yes No Yes NoYes No Yes No49. Have you ever had your spleen removed to treat a blood disorder (e.g., idiopathic thrombocytopenia (ITP),autoimmune hemolytic anemia, other)?Yes No Yes No Yes No Yes No Yes No Yes No50. Have you ever been diagnosed with a sickle cell condition or disease, such as sickle-cell anemia, sicklethalassemia, alpha thalassemia or beta-thalassemia?51. Have you or anyone else in your immediate family ever Yes No Yes No Yes No Yes No Yes No Yes No been diagnosed with any other blood disease ordisorders?If YES, specify type of blood disease and effected family member:Disease: Family Member:Disease: Family Member:Disease: Family Member:Yes No Yes No Yes No Yes No Yes No Yes No52. Have you ever been diagnosed with a metabolic/ storage disease?If YES, specify all that apply in a-o.If NO, go to the next question. a. Hurler Syndrome (MPS I)/ Hurler-ScheieSyndrome (MPS I H-S) b. Hunter Syndrome (MPS II) c. Sanfilippo Syndrome (MPS III) d. Morquio Syndrome (MPS IV) e. Maroteaux-Lamy Syndrome (MPS VI) f. Sly Syndrome (MPS VII) g. I-cell disease h. Globoid Leukodystrophy (Krabbe Disease) i. Metachromatic Leukodystrophy (MLD) j. Adrenoleukodystrophy (ALD) k. Sandhoff Disease l. Tay-Sachs Disease m. Gaucher Disease n. Niemann-Pick Disease o. PorphyriaYes No Yes No Yes No Yes No Yes No Yes No53. Have you ever been diagnosed with Creutzfeldt-Jakob Disease (CJD), variant CJD, dementia, anydegenerative or demyelinating disease of the centralnervous system, or other neurological disease wherethe cause is unknown?Maternal Initials:Maternal DOB (mm/dd/yyyy)://F91226 Health History QuestionnaireRev. 12/19/18; Reviewed 12/19/18Page7

Family Health History y’sGrandparentsYes No Mother’sSiblingsFather’sSiblingsYes No Yes No Yes NoYes No Yes No54. Have you ever been diagnosed with a severe autoimmune disorder?If YES, specify all that apply in a-d.If NO, go to the next question. a. Crohn's Disease or Ulcerative Colitis b. Lupus c. Multiple Sclerosis (MS) d. Rheumatoid ArthritisYesNoYesNoYesNoYesNoYesNoYesNo55. Have you ever had a parasitic blood disease such as Leishmaniasis, Babesiosis, or Chagas disease or hadany positive tests for Tuberculosis, Chagas or T. cruzi,including screening tests?Yes No Yes No Yes No Yes No Yes No Yes No56. Have you ever received a dura mater (brain covering) graft?Yes No Yes No Yes No Yes No Yes No Yes No57. Have you ever had a transplant or other medical procedure that involved being exposed to live cells,tissues, or organs from an animal?Yes No Yes No Yes No Yes No Yes No Yes No58. Have you ever lived with, or had sexual contact with anyone who had a transplant or other medicalprocedure that involved being exposed to live cells,tissues, or organs from an animal?59. Have you had a transplant or tissue graft from someone Yes No Yes No Yes No Yes No Yes No Yes No other than yourself, such as organ, bone marrow, stemcell, cornea, bone, skin, or other tissue?If YES, specify when:60. Have you had your gallbladder removed before age 30? Yes No Yes No Yes No Yes No Yes No Yes No If YES, specify why:61. Have you or anyone else in your immediate family ever Yes No Yes No Yes No Yes No Yes No Yes No had any other serious or life-threatening diseases?If YES, specify type of disease and affected family member(s):Disease: Family Member:Disease: Family Member:Disease: Family Member:Maternal Initials:Maternal DOB (mm/dd/yyyy)://F91226 Health History QuestionnaireRev. 12/19/18; Reviewed 12/19/18Page8

CORD BLOOD DONOR VERIFICATION AND AUTHORIZATION I have read the educational information provided (booklet, rack card etc.) and was given the opportunity to askquestions about cord blood donation and/or raise any concerns.I have had the opportunity to ask questions about the information requested on the Health History Questionnaire.I have truthfully answered all of the questions on the Health History Questionnaire.I understand that the requested information is important because if I am at risk for an infectious or communicablediseas

to donate your cord blood. CORD BLOOD DONATION FACTS To learn more about cord blood banking and donation visit our website or call 315-492-2600 1-855-492-2600 4910 Broad Road Syracuse, NY 13215 www.upstatecordbloodbank.com Cord blood is used in life-saving treatments and research for 80 diseases Cord blood provides patients with a source of .