Summary Profile

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Donor Number: 4034

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:	Yes - Mother (alcohol abuse), age 30, treated by abstaining from alcohol
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	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	61
Health Problem	Alcohol abuse, treated by abstaining from alcohol	30
Health Problem	Esophageal cancer (long-time smoker), successfully treated with surgery	58
Living / Dead	Living

Your Father

Question	Response	Comment/Age Affected
Current age or age at death	73
Health Problem	Prostate cancer, successfully treated with surgery	72
Living / Dead	Living

Brothers

Your Brother 1

Question	Response	Comment/Age Affected
Current age or age at death	34
Health Problem	Healthy
Living / Dead	Living

Daughters

Your Daughter 1

Question	Response	Comment/Age Affected
Current age or age at death	12
Health Problem	Healthy
Living / Dead	Living

Your Daughter 2

Question	Response	Comment/Age Affected
Current age or age at death	7
Health Problem	Healthy
Living / Dead	Living

Your Daughter 3

Question	Response	Comment/Age Affected
Current age or age at death	1
Health Problem	Healthy
Living / Dead	Living

Your Mother's Father

Question	Response	Comment/Age Affected
Current age or age at death	65
Health Problem	Cause of death: Cardiac arrest	65
Living / Dead	Dead

Your Mother's Mother

Question	Response	Comment/Age Affected
Current age or age at death	83
Health Problem	Emphysema (long-time smoker), controlled with a nebulizer	75
	Lung cancer (long-time smoker), no medication or treatment received	83
	Cause of death: Lung cancer	83
Living / Dead	Dead

Your Mother's Brothers 1

Question	Response	Comment/Age Affected
Current age or age at death	63
Health Problem	Healthy
Living / Dead	Living

Your Mother's Brothers 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	62
Health Problem	Heart attack, no medication or treatment received	62
Health Problem	Cause of death: Heart attack	62
Living / Dead	Dead

Your Father's Mother

Question	Response	Comment/Age Affected
Current age or age at death	60
Health Problem	Pneumonia, no medication or treatment received	60
Health Problem	Cause of death: Pneumonia	60
Living / Dead	Dead

Your Father's Sisters 1

Question	Response	Comment/Age Affected
Current age or age at death	76
Health Problem	Heart attack (due to a poor lifestyle), treated with valve replacement surgery	65
Living / Dead	Living

Religion:

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