Summary Profile

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Donor Number: 4710

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	69
Health Problem	Healthy
Living / Dead	Living

Your Father

Question	Response	Comment/Age Affected
Current age or age at death	74
Health Problem	High blood pressure	45
Living / Dead	Living

Sisters

Your Sister 1

Question	Response	Comment/Age Affected
Current age or age at death	44
Health Problem	Healthy
Living / Dead	Living

Your Sister 2

Question	Response	Comment/Age Affected
Current age or age at death	36	(Half-sister)
Health Problem	Healthy
Living / Dead	Living

Your Mother's Father

Question	Response	Comment/Age Affected
Current age or age at death	89
Health Problem	Healthy until death
Health Problem	Cause of death: Heart failure	89
Living / Dead	Dead

Your Mother's Mother

Question	Response	Comment/Age Affected
Current age or age at death	82
Health Problem	Heart attack, not treated	82
Health Problem	Cause of death: Heart attack	82
Living / Dead	Dead

Your Mother's Brothers 1

Question	Response	Comment/Age Affected
Current age or age at death	19
Health Problem	Healthy
Health Problem	Cause of death: Killed in combat (Vietnam)	19
Living / Dead	Dead

Your Father's Father

Question	Response	Comment/Age Affected
Current age or age at death	79
Health Problem	Emphysema from asbestos exposure, treated with oxygen	75
Health Problem	Cause of death: Emphysema	79
Living / Dead	Dead

Your Father's Mother

Question	Response	Comment/Age Affected
Current age or age at death	92
Health Problem	Healthy
	Stillbirth	26
	Cause of death: Heart failure	92
Living / Dead	Dead

Your Father's Sisters 1

Question	Response	Comment/Age Affected
Current age or age at death	67
Health Problem	Healthy
Living / Dead	Living

Your Father's Brothers 1

Question	Response	Comment/Age Affected
Current age or age at death	N/A
Health Problem	Died at birth due to unsafe medical practices
Living / Dead	Dead

Religion:

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