| Physical |
| Race |
Caucasian |
| Ethnic Background |
German/German |
| Height |
6'1'' |
| Weight |
185 |
| Eye Color |
Hazel |
| Hair |
Blond/Straight |
| Skin Tone |
Medium |
| Blood Type |
A+ |
| Education |
M.P.H/Epidemiology student |
| Occupation |
Graduate student |
| Interests |
Recreational basketball, running/jogging,chess,music |
| Medical |
| Question | Response | Comment |
Any dietary restriction?
If yes, explain: | No | |
Do you wear glasses or contact lenses?
Are you near or far-sighted? | Yes | Near-Sighted |
Allergies (medicines, food, pollens)?
If yes, please list substance and reaction caused: | Yes | Mild seasonal allergies - sneezing and watery eyes |
| Your Mother |
| Question | Response | Comment/Age Affected |
| Current age or age at death | 57 | |
| Health Problem | Healthy |
| Living / Dead | Living | |
| Your Father |
| Question | Response | Comment/Age Affected |
| Current age or age at death | 59 | |
| Health Problem | Healthy |
| Living / Dead | Living | |
| Your Sister 1 |
| Question | Response | Comment/Age Affected |
| Current age or age at death | 27 | |
| Health Problem | Healthy |
| Living / Dead | Living | |
| Your Sister 2 |
| Question | Response | Comment/Age Affected |
| Current age or age at death | 21 | |
| Health Problem | Healthy |
| Living / Dead | Living | |
| Your Mother's Father |
| Question | Response | Comment/Age Affected |
| Current age or age at death | 91 | |
| Health Problem | Healthy |
| Living / Dead | Living | |
| Your Mother's Mother |
| Question | Response | Comment/Age Affected |
| Current age or age at death | 86 | |
| Health Problem | Died of pnemonia |
| Living / Dead | Dead | |
| Your Mother's Sisters 1 |
| Question | Response | Comment/Age Affected |
| Current age or age at death | 60 | |
| Health Problem | Healthy |
| Living / Dead | Living | |
| Your Mother's Brothers 1 |
| Question | Response | Comment/Age Affected |
| Current age or age at death | 61 | |
| Health Problem | Healthy |
| Living / Dead | Living | |
| Your Mother's Brothers 2 |
| Question | Response | Comment/Age Affected |
| Current age or age at death | 63 | |
| Health Problem | Healthy |
| Living / Dead | Living | |
| Your Father's Father |
| Question | Response | Comment/Age Affected |
| Current age or age at death | 71 | |
| Health Problem | Died from lung cancer-non smoker |
71 |
| Living / Dead | Dead | |
| Your Father's Mother |
| Question | Response | Comment/Age Affected |
| Current age or age at death | 90 | |
| Health Problem |
May move to assisted living b/c having problems with everyday activities |
|
| Living / Dead | Living | |
| Your Father's Brothers 1 |
| Question | Response | Comment/Age Affected |
| Current age or age at death | 60 | |
| Health Problem | Healthy |
| Living / Dead | Living | |
| Your Father's Brothers 2 |
| Question | Response | Comment/Age Affected |
| Current age or age at death | 57 | |
| Health Problem | Healthy |
| Living / Dead | Living | |
| Your Father's Brothers 3 |
| Question | Response | Comment/Age Affected |
| Current age or age at death | 54 | |
| Health Problem | Healthy |
| Living / Dead | Living | |
| Your Father's Brothers 4 |
| Question | Response | Comment/Age Affected |
| Current age or age at death | 51 | |
| Health Problem | Healthy |
| Living / Dead | Living | |