Fairfax Cryobank |
Donor 2184 Summary Profile |
Questions |
Physical |
Medical |
Family Medical History |
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 | ||
Question | Response | |
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 Antibody | Positive | |
CMV IgM Antibody | Negative | |
Note any comments regarding above items: | N/A | |
Any other comments | N/A |
Family Medical History |
Your MotherQuestion | Response | Comment/Age Affected | Current age or age at death | | 56 | Health Problem |
Living / Dead | Living | |
|
Your FatherQuestion | Response | Comment/Age Affected | Current age or age at death | | 56 | Health Problem |
Living / Dead | Living | |
|
Brother(s) |
Your Brother 1Question | Response | Comment/Age Affected | Current age or age at death | | 30 | Health Problem |
Living / Dead | Living | |
|
Sister(s) |
Your Sister 1Question | Response | Comment/Age Affected | Current age or age at death | | 28 | Health Problem |
Living / Dead | Living | |
|
Your Mother's FatherQuestion | Response | Comment/Age Affected | Current age or age at death | | 65 | Health Problem |
Living / Dead | Dead | |
|
Your Mother's MotherQuestion | Response | Comment/Age Affected | Current age or age at death | | 79 | Health Problem |
Living / Dead | Living | |
|
Your Mother's Sisters 1Question | Response | Comment/Age Affected | Current age or age at death | | 48 | Health Problem |
Living / Dead | Living | | |
Your Mother's Sisters 2Question | Response | Comment/Age Affected | Current age or age at death | | 50 | Health Problem |
Living / Dead | Living | |
|
Your Mother's Brothers 1Question | Response | Comment/Age Affected | Current age or age at death | | 60 | Health Problem |
Living / Dead | Living | |
|
Your Father's FatherQuestion | Response | Comment/Age Affected | Current age or age at death | | 68 | Health Problem |
Living / Dead | Dead | |
|
Your Father's MotherQuestion | Response | Comment/Age Affected | Current age or age at death | | 50 | Health Problem |
Living / Dead | Dead | |
|
Your Father's Sisters 1Question | Response | Comment/Age Affected | Current age or age at death | | 62 | Health Problem |
Living / Dead | Living | |
|