Summary Profile

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Donor Number: 4594

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?	Yes - Near-sighted
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	57
Health Problem	Healthy
Living / Dead	Living

Your Father

Question	Response	Comment/Age Affected
Current age or age at death	58
Health Problem	Healthy
Living / Dead	Living

Brothers

Your Brother 1

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

Sisters

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	25
Health Problem	Healthy
Living / Dead	Living

Your Mother's Father

Question	Response	Comment/Age Affected
Current age or age at death	85
Health Problem	Skin cancer, treated with surgery	78
	Heart attack, treated with bypass surgery and medication	82
	Diabetes mellitus not requiring insulin therapy, controlled with diet management	83
Living / Dead	Living

Your Mother's Mother

Question	Response	Comment/Age Affected
Current age or age at death	72
Health Problem	Broken hip, required hospitalization	72
Health Problem	Cause of death: Complications due to broken hip	72
Living / Dead	Dead

Your Father's Father

Question	Response	Comment/Age Affected
Current age or age at death	91
Health Problem	Broken hip, required hospitalization	91
Health Problem	Cause of death: Complications due to broken hip	91
Living / Dead	Dead

Your Father's Mother

Question	Response	Comment/Age Affected
Current age or age at death	85
Health Problem	Stroke, no treatment	85
Health Problem	Cause of death: Stroke	85
Living / Dead	Dead

Your Father's Sisters 1

Question	Response	Comment/Age Affected
Current age or age at death	53
Health Problem	Healthy
Living / Dead	Living

Your Father's Brothers 1

Question	Response	Comment/Age Affected
Current age or age at death	55
Health Problem	Hydrocephalus, since birth, no treatment
	Mental retardation, no treatment, caused by hydrocephalus
	Stomach cancer, no treatment	54
	Cause of death: Stomach cancer	55
Living / Dead	Dead

Religion:

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