Summary Profile

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Donor Number: 2775

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:	No
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:	No
CMV IgG Antibody	Positive
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	67
Health Problem	Miscarriage	34
Living / Dead	Living

Your Father

Question	Response	Comment/Age Affected
Current age or age at death	79
Health Problem	Healthy
Health Problem	Cause of death: Died in his sleep, no autopsy	79
Living / Dead	Dead

Brothers

Your Brother 1

Question	Response	Comment/Age Affected
Current age or age at death	38
Health Problem	Healthy
Living / Dead	Living

Sisters

Your Sister 1

Question	Response	Comment/Age Affected
Current age or age at death	31
Health Problem	Healthy
Living / Dead	Living

Daughters

Your Daughter 1

Question	Response	Comment/Age Affected
Current age or age at death	5
Health Problem	Seasonal allergies	2
	Asthma	2
	Peanut allergy	2
Living / Dead	Living

Your Daughter 2

Question	Response	Comment/Age Affected
Current age or age at death	3
Health Problem	Allergic to dairy, eggs, peanuts and white fish	1
Health Problem	Seasonal allergies	1
Living / Dead	Living

Your Mother's Father

Question	Response	Comment/Age Affected
Current age or age at death	76
Health Problem	High blood pressure	65
Health Problem	Cause of death: Stroke	76
Living / Dead	Dead

Your Mother's Mother

Question	Response	Comment/Age Affected
Current age or age at death	93
Health Problem	Osteoporosis	80
	High blood pressure	80
	Stroke	92
	Cause of death: Complications of high blood pressure and stroke	93
Living / Dead	Dead

Your Mother's Sisters 1

Question	Response	Comment/Age Affected
Current age or age at death	61
Health Problem	Healthy
Living / Dead	Living

Your Father's Father

Question	Response	Comment/Age Affected
Current age or age at death	66
Health Problem	Heart attack	66
Health Problem	Cause of death: Heart attack	66
Living / Dead	Dead

Your Father's Mother

Question	Response	Comment/Age Affected
Current age or age at death	73
Health Problem	Stroke	73
Health Problem	Cause of death: Stroke	73
Living / Dead	Dead

Your Father's Sisters 1

Question	Response	Comment/Age Affected
Current age or age at death	76
Health Problem	Healthy
Living / Dead	Living

Religion:

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