Fairfax Cryobank
Donor 2184 Summary Profile





Questions
Physical
Medical
Family Medical History

Physical
Race Cauc
Ethnic Background German-English/Italian-English
Height 6'1''
Weight 180
Eye Color Green
Hair Brown/Wavy
Skin Tone Meddk
Blood Type O-
Education MS Interdisciplinary Stdy/
Occupation Art Teacher
Interests Writing/Travel/Guitar

Medical
QuestionResponse
Any dietary restriction?
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 - Pollens in spring and summer
CMV IgG AntibodyPositive
CMV IgM AntibodyNegative
Note any comments regarding above items: N/A
Any other comments N/A

Family Medical History

Your Mother
QuestionResponseComment/Age Affected
 Current age or age at death    56 
 Health Problem
 Thyroid problems - on medication, overweight 50
 Living / Dead Living  

Your Father
QuestionResponseComment/Age Affected
 Current age or age at death    56 
 Health Problem
 Arthritis 40
 Living / Dead Living  

Brother(s)

Your Brother 1
QuestionResponseComment/Age Affected
 Current age or age at death    30 
 Health Problem
 Healthy 
 Living / Dead Living  

Sister(s)

Your Sister 1
QuestionResponseComment/Age Affected
 Current age or age at death    28 
 Health Problem
 Healthy 
 Living / Dead Living  

Your Mother's Father
QuestionResponseComment/Age Affected
 Current age or age at death    65 
 Health Problem
 Sudden heart attack 65
 Living / Dead Dead  

Your Mother's Mother
QuestionResponseComment/Age Affected
 Current age or age at death    79 
 Health Problem
 Cataracts 70
 Arthritis 50
 Living / Dead Living  

Your Mother's Sisters 1
QuestionResponseComment/Age Affected
 Current age or age at death    48 
 Health Problem
 Healthy 
 Living / Dead Living  

Your Mother's Sisters 2
QuestionResponseComment/Age Affected
 Current age or age at death    50 
 Health Problem
 Healthy 
 Living / Dead Living  

Your Mother's Brothers 1
QuestionResponseComment/Age Affected
 Current age or age at death    60 
 Health Problem
 Healthy 
 Living / Dead Living  

Your Father's Father
QuestionResponseComment/Age Affected
 Current age or age at death    68 
 Health Problem
 Died after a fall down stairs 
 Living / Dead Dead  

Your Father's Mother
QuestionResponseComment/Age Affected
 Current age or age at death    50 
 Health Problem
 Was an amputee, cause of death due to complications 
 Living / Dead Dead  

Your Father's Sisters 1
QuestionResponseComment/Age Affected
 Current age or age at death    62 
 Health Problem
 Healthy 
 Living / Dead Living