Summary Profile

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Donor Number: 4505

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	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	48
Health Problem	Healthy
Living / Dead	Living

Your Father

Question	Response	Comment/Age Affected
Current age or age at death	50
Health Problem	Healthy
Living / Dead	Living

Your Mother's Father

Question	Response	Comment/Age Affected
Current age or age at death	63
Health Problem	Liver enlargement (did not smoke or drink), treated with surgery	62
Health Problem	Cause of death: Liver failure	63
Living / Dead	Dead

Your Mother's Mother

Question	Response	Comment/Age Affected
Current age or age at death	70
Health Problem	Diabetes mellitus not requiring insulin therapy, treated through diet control	64
Living / Dead	Living

Your Mother's Sisters 1

Question	Response	Comment/Age Affected
Current age or age at death	46
Health Problem	Healthy
Living / Dead	Living

Your Father's Father

Question	Response	Comment/Age Affected
Current age or age at death	88
Health Problem	Chronic heartburn, treated with over-the-counter medication	70
Living / Dead	Living

Your Father's Mother

Question	Response	Comment/Age Affected
Current age or age at death	73
Health Problem	Heart attack, no medication or treatment received	73
Health Problem	Cause of death: Heart attack	73
Living / Dead	Dead

Your Father's Sisters 1

Question	Response	Comment/Age Affected
Current age or age at death	54
Health Problem	Healthy
Living / Dead	Living

Your Father's Sisters 2

Question	Response	Comment/Age Affected
Current age or age at death	52
Health Problem	Healthy
Living / Dead	Living

Your Father's Brothers 1

Question	Response	Comment/Age Affected
Current age or age at death	48
Health Problem	Healthy
Living / Dead	Living

Your Father's Brothers 2

Question	Response	Comment/Age Affected
Current age or age at death	45
Health Problem	Healthy
Living / Dead	Living

Religion:

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