Summary Profile

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Donor Number: 4849

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	Positive
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	56
Health Problem	High blood pressure, no treatment	55
Living / Dead	Living

Your Father

Question	Response	Comment/Age Affected
Current age or age at death	56
Health Problem	Rheumatoid arthritis, controlled with medication	54
Health Problem	High blood pressure, controlled with medication	55
Living / Dead	Living

Brothers

Your Brother 1

Question	Response	Comment/Age Affected
Current age or age at death	27
Health Problem	Healthy
Living / Dead	Living

Your Mother's Father

Question	Response	Comment/Age Affected
Current age or age at death	86
Health Problem	High blood pressure, controlled with medication	60
	Diabetes mellitus not requiring insulin therapy, controlled with diet modifications	65
	Heart attack, treated with bypass surgery	72
	Heart attack, no treatment	86
	Cause of death: Heart attack	86
Living / Dead	Dead

Your Mother's Mother

Question	Response	Comment/Age Affected
Current age or age at death	92
Health Problem	Dementia, in-home care, no other treatment	88
	Congestive heart failure, no treatment	92
	Cause of death: Congestive heart failure	92
Living / Dead	Dead

Your Mother's Sisters 1

Question	Response	Comment/Age Affected
Current age or age at death	64
Health Problem	Healthy
Living / Dead	Living

Your Mother's Sisters 2

Question	Response	Comment/Age Affected
Current age or age at death	62
Health Problem	Healthy
Living / Dead	Living

Your Father's Father

Question	Response	Comment/Age Affected
Current age or age at death	93
Health Problem	Diabetes mellitus requiring insulin therapy	85
Living / Dead	Living

Your Father's Mother

Question	Response	Comment/Age Affected
Current age or age at death	81
Health Problem	Rheumatoid arthritis, controlled with medication	70
	Congestive heart failure, no treatment	81
	Cause of death: Congestive heart failure	81
Living / Dead	Dead

Your Father's Sisters 1

Question	Response	Comment/Age Affected
Current age or age at death	61
Health Problem	Healthy
Living / Dead	Living

Your Father's Brothers 1

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

Your Father's Brothers 2

Question	Response	Comment/Age Affected
Current age or age at death	64
Health Problem	Prostate cancer, treated with medication	58
Living / Dead	Living

Religion:

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