Summary Profile

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Donor Number: 4824

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	55
Health Problem	Sleep apnea, controlled with CPAP machine	41
Living / Dead	Living

Your Father

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

Brothers

Your Brother 1

Question	Response	Comment/Age Affected
Current age or age at death	26
Health Problem	Healthy
Living / Dead	Living

Your Mother's Father

Question	Response	Comment/Age Affected
Current age or age at death	55
Health Problem	Brain aneurysm, no treatment	55
Health Problem	Cause of death: Brain aneurysm	55
Living / Dead	Dead

Your Mother's Mother

Question	Response	Comment/Age Affected
Current age or age at death	63
Health Problem	Lung cancer, no treatment	62
Health Problem	Cause of death: Lung cancer	63
Living / Dead	Dead

Your Mother's Brothers 1

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

Your Mother's Brothers 2

Question	Response	Comment/Age Affected
Current age or age at death	57
Health Problem	Healthy
Living / Dead	Living

Your Mother's Brothers 3

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

Your Father's Father

Question	Response	Comment/Age Affected
Current age or age at death	75
Health Problem	Diabetes mellitus requiring insulin therapy	60
	Prostate cancer, treated with surgery	64
	Poor circulation, treated with heart surgery	70
Living / Dead	Living

Your Father's Mother

Question	Response	Comment/Age Affected
Current age or age at death	74
Health Problem	Healthy
Living / Dead	Living

Your Father's Sisters 1

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

Religion:

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