Summary Profile

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Donor Number: 4722

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:	Yes - Pollen: Stuffy nose
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	59
Health Problem	Healthy
Living / Dead	Living

Your Father

Question	Response	Comment/Age Affected
Current age or age at death	58
Health Problem	Skin cancer, small spot on arm, treated with surgery	50
Living / Dead	Living

Sisters

Your Sister 1

Question	Response	Comment/Age Affected
Current age or age at death	27
Health Problem	Healthy
Health Problem	Partially deaf since 6 months old (resulting from a high fever)	1
Living / Dead	Living

Your Mother's Father

Question	Response	Comment/Age Affected
Current age or age at death	76
Health Problem	Stroke (treated with physical and speech therapy)	72
Health Problem	Cause of death: Heart failure	76
Living / Dead	Dead

Your Mother's Mother

Question	Response	Comment/Age Affected
Current age or age at death	85
Health Problem	Healthy
Living / Dead	Living

Your Mother's Sisters 1

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

Your Mother's Sisters 2

Question	Response	Comment/Age Affected
Current age or age at death	51
Health Problem	Healthy
Living / Dead	Living

Your Father's Father

Question	Response	Comment/Age Affected
Current age or age at death	69
Health Problem	High blood pressure (treated with change in lifestyle)	63
	Pneumonia (treated with hospitalization)	68
	Pneumonia (treated with hospitalization)	69
	Cause of death: Pneumonia	69
Living / Dead	Dead

Your Father's Mother

Question	Response	Comment/Age Affected
Current age or age at death	87
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	Healthy
Living / Dead	Living

Your Father's Brothers 2

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

Religion:

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