Summary Profile

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Donor Number: 4857

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	57
Health Problem	Healthy
Living / Dead	Living

Your Father

Question	Response	Comment/Age Affected
Current age or age at death	62
Health Problem	Osteoarthritis, controlled with over-the-counter medication	60
Living / Dead	Living

Brothers

Your Brother 1

Question	Response	Comment/Age Affected
Current age or age at death	34
Health Problem	Situational depression, controlled with medication	28
Living / Dead	Living

Your Mother's Father

Question	Response	Comment/Age Affected
Current age or age at death	85
Health Problem	Glaucoma, treated with medicated eye drops	82
	Dementia, no treatment	85
	Congestive heart failure, no treatment	85
	Cause of death: Congestive heart failure	85
Living / Dead	Dead

Your Mother's Mother

Question	Response	Comment/Age Affected
Current age or age at death	87
Health Problem	High blood pressure, controlled with diet modifications and medication	80
	Pneumonia, hospitalization	87
	Cause of death: Pneumonia	87
Living / Dead	Dead

Your Mother's Sisters 1

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

Your Mother's Brothers 1

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

Your Father's Father

Question	Response	Comment/Age Affected
Current age or age at death	64
Health Problem	Lung cancer (smoker), no treatment	64
Health Problem	Cause of death: Lung cancer	64
Living / Dead	Dead

Your Father's Mother

Question	Response	Comment/Age Affected
Current age or age at death	77
Health Problem	Broken hip due to fall, hospitalized	77
Health Problem	Cause of death: Complications of broken hip	77
Living / Dead	Dead

Your Father's Sisters 1

Question	Response	Comment/Age Affected
Current age or age at death	65
Health Problem	Healthy
Living / Dead	Living

Your Father's Sisters 2

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

Your Father's Brothers 1

Question	Response	Comment/Age Affected
Current age or age at death	44
Health Problem	Mentally handicapped since birth, no treatment
Living / Dead	Living

Religion:

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