Summary Profile

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Donor Number: 4567

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 - Bee stings: Swelling at site of sting; Gantrisin/Ceclor/Zithromax: Hives
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	50
Health Problem	Healthy
Living / Dead	Living

Your Father

Question	Response	Comment/Age Affected
Current age or age at death	55
Health Problem	Arthritis (mild) of the hands and elbows, treated with over-the-counter medication	50
Living / Dead	Living

Sisters

Your Sister 1

Question	Response	Comment/Age Affected
Current age or age at death	21
Health Problem	Healthy
Living / Dead	Living

Your Sister 2

Question	Response	Comment/Age Affected
Current age or age at death	14
Health Problem	Pneumonia, treated with antibiotics	8
Living / Dead	Living

Your Mother's Father

Question	Response	Comment/Age Affected
Current age or age at death	73
Health Problem	Healthy
Living / Dead	Living

Your Mother's Mother

Question	Response	Comment/Age Affected
Current age or age at death	71
Health Problem	Alzheimer's, treated with medication	70
Health Problem	Diabetes mellitus not requiring insulin therapy, diet-controlled	71
Living / Dead	Living

Your Mother's Brothers 1

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

Your Mother's Brothers 2

Question	Response	Comment/Age Affected
Current age or age at death	47
Health Problem	Healthy
Living / Dead	Living

Your Mother's Brothers 3

Question	Response	Comment/Age Affected
Current age or age at death	42
Health Problem	Healthy
Living / Dead	Living

Your Father's Father

Question	Response	Comment/Age Affected
Current age or age at death	84
Health Problem	Healthy
Living / Dead	Living

Your Father's Mother

Question	Response	Comment/Age Affected
Current age or age at death	84
Health Problem	Breast cancer, treated with surgery	60
Living / Dead	Living

Your Father's Brothers 1

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

Religion:

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