Summary Profile

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Donor Number: 5224

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?	Yes - Near-sighted
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
See list of questions asked here

Your Mother

Question	Response	Comment/Age Affected
Current age or age at death	60
Health Problem	Breast cancer, treated with surgery	55
Living / Dead	Living

Your Father

Question	Response	Comment/Age Affected
Current age or age at death	70
Health Problem	Prostate cancer, treated with surgery	60
	High blood pressure, controlled with medication	62
	Kidney stone, passed naturally	62
Living / Dead	Living

Sisters

Your Sister 1

Question	Response	Comment/Age Affected
Current age or age at death	31
Health Problem	Healthy
Living / Dead	Living

Your Mother's Father

Question	Response	Comment/Age Affected
Current age or age at death	85
Health Problem	Bladder cancer, in his early 70s, treated with surgery	70
Living / Dead	Living

Your Mother's Mother

Question	Response	Comment/Age Affected
Current age or age at death	75
Health Problem	Thyroid cancer, treated with chemotherapy and palliative care	75
Health Problem	Cause of death: Thyroid cancer	75
Living / Dead	Dead

Your Mother's Sisters 1

Question	Response	Comment/Age Affected
Current age or age at death	52
Health Problem	Healthy
Living / Dead	Living

Your Father's Father

Question	Response	Comment/Age Affected
Current age or age at death	65
Health Problem	Heart attack, no treatment	65
Health Problem	Cause of death: Heart attack	65
Living / Dead	Dead

Your Father's Mother

Question	Response	Comment/Age Affected
Current age or age at death	60
Health Problem	Esophageal cancer (smoker, diagnosed at her death), no treatment	60
Health Problem	Cause of death: Esophageal cancer	60
Living / Dead	Dead

Your Father's Sisters 1

Question	Response	Comment/Age Affected
Current age or age at death	62
Health Problem	Healthy
Living / Dead	Living

Religion:

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