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Donor Number: 2757

Profile:

Family Medical History

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Physical

Medical

Question	Response
Have you or any of your family members been diagnosed with alcoholism or drug addiction? If yes, relation and age affected:	Yes - Maternal grandfather, age 50
Any dietary restrictions? If yes, explain:	No
Do you wear glasses or contact lenses? Are you near or far-sighted?	No
Allergies (medicines, food, pollens)? If yes, please list substance and reaction caused:	Yes - Tree pollen: Causes runny nose, watery eyes
CMV IgG Antibody	Negative
CMV IgM Antibody	Negative
Note any comments regarding above items:	N/A

Family Medical History
See list of questions asked here

Your Mother

Question	Response	Comment/Age Affected
Current age or age at death	66
Health Problem	Miscarriage (between two healthy pregnancies)	28
	Miscarriage (between two healthy pregnancies)	30
	Deviated septum, corrected with surgery	45
Living / Dead	Living

Your Father

Question	Response	Comment/Age Affected
Current age or age at death	72
Health Problem	Pneumonia, no treatment	40
Living / Dead	Living

Brothers

Your Brother 1

Question	Response	Comment/Age Affected
Current age or age at death	29
Health Problem	Healthy
Living / Dead	Living

Sisters

Your Sister 1

Question	Response	Comment/Age Affected
Current age or age at death	40
Health Problem	Healthy
Living / Dead	Living

Your Sister 2

Question	Response	Comment/Age Affected
Current age or age at death	33
Health Problem	Healthy
Living / Dead	Living

Your Sister 3

Question	Response	Comment/Age Affected
Current age or age at death	30
Health Problem	Healthy
Living / Dead	Living

Your Sister 4

Question	Response	Comment/Age Affected
Current age or age at death	24
Health Problem	Healthy
Living / Dead	Living

Your Mother's Father

Question	Response	Comment/Age Affected
Current age or age at death	75
Health Problem	Alcoholic, no treatment	50
	Liver cirrhosis (alcoholic), treated with change in diet	60
	Cause of death: Liver cirrhosis	75
Living / Dead	Dead

Your Mother's Mother

Question	Response	Comment/Age Affected
Current age or age at death	76
Health Problem	Cause of death unknown, died in sleep with no known health problems	76
Living / Dead	Dead

Your Mother's Brothers 1

Question	Response	Comment/Age Affected
Current age or age at death	68
Health Problem	Healthy
Living / Dead	Living

Your Father's Father

Question	Response	Comment/Age Affected
Current age or age at death	88
Health Problem	Skin cancer on lip, treated with surgery to remove	75
	Heart attack, treated with bypass surgery	80
	Heart failure	88
	Cause of death: Heart failure	88
Living / Dead	Dead

Your Father's Mother

Question	Response	Comment/Age Affected
Current age or age at death	40
Health Problem	Ovarian cancer, no treatment	40
Health Problem	Cause of death: Ovarian cancer	40
Living / Dead	Dead

Your Father's Sisters 1

Question	Response	Comment/Age Affected
Current age or age at death	65
Health Problem	Diabetes, diet controlled	50
	Uterine cancer, attempted treatment with surgery	65
	Cause of death: Cancer surgery complications	65
Living / Dead	Dead

Religion:

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