Fairfax Cryobank |
Donor 2700 Summary Profile |
Questions |
Physical |
Medical |
Family Medical History |
Updates to Profile |
Race | Cauc |
Ethnic Background | Swedish-Irish/English |
Height | 5'11'' |
Weight | 180 |
Eye Color | Green |
Hair | Red/Wavy |
Skin Tone | Light |
Blood Type | A- |
Education | MD/Medicine/ |
Occupation | Resident Physician |
Interests | Aquarium/Sprts/Outdrs |
Medical | ||
Question | Response | |
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: | Yes - Pollen: Itchy skin and sneezing | |
CMV IgG Antibody | Positive | |
CMV IgM Antibody | Negative | |
Note any comments regarding above items: | N/A |
Family Medical History |
Your MotherQuestion | Response | Comment/Age Affected | Current age or age at death | 59 | | Health Problem |
Living / Dead | Living | |
|
Your FatherQuestion | Response | Comment/Age Affected | Current age or age at death | 57 | | Health Problem |
Living / Dead | Living | |
|
Sister(s) |
Your Sister 1Question | Response | Comment/Age Affected | Current age or age at death | 21 | | Health Problem |
Living / Dead | Living | |
|
Son(s) |
Your Son 1Question | Response | Comment/Age Affected | Current age or age at death | 12 | | Health Problem |
Living / Dead | Living | |
|
Daughter(s) |
Your Daughter 1Question | Response | Comment/Age Affected | Current age or age at death | 9 | | Health Problem |
Living / Dead | Living | | |
Your Daughter 2Question | Response | Comment/Age Affected | Current age or age at death | 2.5 | | Health Problem |
Living / Dead | Living | |
|
Your Mother's FatherQuestion | Response | Comment/Age Affected | Current age or age at death | 80 | | Health Problem |
Living / Dead | Dead | |
|
Your Mother's MotherQuestion | Response | Comment/Age Affected | Current age or age at death | 83 | | Health Problem |
Living / Dead | Living | |
|
Your Father's FatherQuestion | Response | Comment/Age Affected | Current age or age at death | 84 | | Health Problem |
Living / Dead | Dead | |
|
Religion: | ||
Faith | None - Agnostic | |
Denomination | N/A |
Updates to Profile | ||
Update Available | N/A | |
Updates - Personal | N/A | |
Updates - Medical | Adopted son, 12 years old, Healthy - updated 10/23/08 | |
Updates - Family Medical History | N/A |