Summary Profile

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Donor Number: 4811

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	65
Health Problem	Zygodactyly, no treatment
Health Problem	Skin cancer on face, removed with surgery	61
Living / Dead	Living

Your Father

Question	Response	Comment/Age Affected
Current age or age at death	68
Health Problem	Diabetes mellitus requiring insulin therapy, due to being overweight	60
Health Problem	Stroke, treated with physical therapy	65
Living / Dead	Living

Brothers

Your Brother 1

Question	Response	Comment/Age Affected
Current age or age at death	30	(in his 30s)
Health Problem	Healthy
Living / Dead	Living

Your Brother 2

Question	Response	Comment/Age Affected
Current age or age at death	20	(in his 20s)
Health Problem	Acne, treated with over-the-counter cream	14
Living / Dead	Living

Your Mother's Father

Question	Response	Comment/Age Affected
Current age or age at death	68
Health Problem	Heart attack, no treatment	68
Health Problem	Cause of death: Heart attack	68
Living / Dead	Dead

Your Mother's Mother

Question	Response	Comment/Age Affected
Current age or age at death	86
Health Problem	Healthy
Living / Dead	Living

Your Mother's Brothers 1

Question	Response	Comment/Age Affected
Current age or age at death	54
Health Problem	Concussion, no treatment	54
	Severe trauma due to car accident	54
	Cause of death: Severe trauma due to car accident	54
Living / Dead	Dead

Your Mother's Brothers 2

Question	Response	Comment/Age Affected
Current age or age at death	65
Health Problem	Healthy
Living / Dead	Living

Your Father's Father

Question	Response	Comment/Age Affected
Current age or age at death	65
Health Problem	Colon cancer, attempted treatment with surgery	62
Health Problem	Cause of death: Colon cancer	65
Living / Dead	Dead

Your Father's Mother

Question	Response	Comment/Age Affected
Current age or age at death	86
Health Problem	Dementia, no treatment	79
Living / Dead	Living

Religion:

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