Summary Profile

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Donor Number: 4383

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:	N/A
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
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Your Mother

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

Your Father

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

Your Mother's Father

Question	Response	Comment/Age Affected
Current age or age at death	72
Health Problem	MRSA Infection, treated in hospital	72
Health Problem	Cause of death: MRSA infection	72
Living / Dead	Dead

Your Mother's Mother

Question	Response	Comment/Age Affected
Current age or age at death	70
Health Problem	Healthy	70
Living / Dead	Living

Your Father's Father

Question	Response	Comment/Age Affected
Current age or age at death	75
Health Problem	Oral cancer, treated with surgery	72
Health Problem	Cause of death: Oral cancer	75
Living / Dead	Dead

Your Father's Mother

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

Religion:

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