Summary Profile

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Donor Number: 4935

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	Positive
CMV IgM Antibody	Negative
Note any comments regarding above items:	N/A

Family Medical History
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Your Mother

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

Your Father

Question	Response	Comment/Age Affected
Current age or age at death	59
Health Problem	Healthy
Living / Dead	Living

Brothers

Your Brother 1

Question	Response	Comment/Age Affected
Current age or age at death	31
Health Problem	Healthy
Living / Dead	Living

Your Mother's Father

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

Your Mother's Mother

Question	Response	Comment/Age Affected
Current age or age at death	75
Health Problem	Pneumonia, treated in hospital	75
Health Problem	Cause of death: Pneumonia	75
Living / Dead	Dead

Your Mother's Sisters 1

Question	Response	Comment/Age Affected
Current age or age at death	60
Health Problem	Healthy
Living / Dead	Living

Your Mother's Sisters 2

Question	Response	Comment/Age Affected
Current age or age at death	56
Health Problem	Healthy
Living / Dead	Living

Your Mother's Brothers 1

Question	Response	Comment/Age Affected
Current age or age at death	52
Health Problem	Healthy
Living / Dead	Living

Your Father's Father

Question	Response	Comment/Age Affected
Current age or age at death	82
Health Problem	Pneumonia, treated in hospital	82
Health Problem	Cause of death: Pneumonia	82
Living / Dead	Dead

Your Father's Mother

Question	Response	Comment/Age Affected
Current age or age at death	92
Health Problem	Broken hip, treated in hospital	92
Health Problem	Cause of death: Complications of broken hip	92
Living / Dead	Dead

Religion:

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