Summary Profile

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Donor Number: 5016

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 - Paternal uncle, age 50
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
See list of questions asked here

Your Mother

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

Your Father

Question	Response	Comment/Age Affected
Current age or age at death	66
Health Problem	Kidney stones, treated with lithotripsy and diet change	20
	High blood pressure, treated with diet and lifestyle changes	45
	Melanoma, late stage, treated with palliative care only	66
	Cause of death: Melanoma	66
Living / Dead	Dead

Sisters

Your Sister 1

Question	Response	Comment/Age Affected
Current age or age at death	32
Health Problem	Healthy
Living / Dead	Living

Your Mother's Father

Question	Response	Comment/Age Affected
Current age or age at death	85
Health Problem	Diabetes mellitus not requiring insulin therapy, treated with diet and lifestyle changes	75
Health Problem	Cause of death: Heart failure	85
Living / Dead	Dead

Your Mother's Mother

Question	Response	Comment/Age Affected
Current age or age at death	84
Health Problem	Ovarian cancer, treated with surgery and chemotherapy	75
Living / Dead	Living

Your Mother's Sisters 1

Question	Response	Comment/Age Affected
Current age or age at death	59
Health Problem	Melanoma, treated with surgery	55
Living / Dead	Living

Your Mother's Sisters 2

Question	Response	Comment/Age Affected
Current age or age at death	57
Health Problem	Healthy
Living / Dead	Living

Your Mother's Sisters 3

Question	Response	Comment/Age Affected
Current age or age at death	51
Health Problem	Healthy
Living / Dead	Living

Your Mother's Brothers 1

Question	Response	Comment/Age Affected
Current age or age at death	46
Health Problem	Diabetes mellitus requiring insulin therapy	30
Living / Dead	Living

Your Father's Father

Question	Response	Comment/Age Affected
Current age or age at death	70
Health Problem	High blood pressure, treated with medication	60
	Heart failure, no treatment	70
	Cause of death: Heart failure	70
Living / Dead	Dead

Your Father's Mother

Question	Response	Comment/Age Affected
Current age or age at death	84
Health Problem	Ovarian cancer, treated with surgery and chemotherapy	82
Health Problem	Cause of death: Ovarian cancer	84
Living / Dead	Dead

Your Father's Brothers 1

Question	Response	Comment/Age Affected
Current age or age at death	61
Health Problem	Healthy
Health Problem	Alcoholism, treated through Alcoholics Anonymous and with rehabilitation	50
Living / Dead	Living

Religion:

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