Fairfax Cryobank
Donor 2700 Summary Profile






Questions
Physical
Medical
Family Medical History
Updates to Profile

Physical
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
QuestionResponse
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 AntibodyPositive
CMV IgM AntibodyNegative
Note any comments regarding above items: N/A

Family Medical History

Your Mother
QuestionResponseComment/Age Affected
 Current age or age at death  59   
 Health Problem
 Obesity 40
 Living / Dead Living  

Your Father
QuestionResponseComment/Age Affected
 Current age or age at death  57   
 Health Problem
 Benign throat tumor 44
 Living / Dead Living  

Sister(s)

Your Sister 1
QuestionResponseComment/Age Affected
 Current age or age at death  21   
 Health Problem
 Healthy 
 Living / Dead Living  

Son(s)

Your Son 1
QuestionResponseComment/Age Affected
 Current age or age at death  12   
 Health Problem
 Adopted 12
 Healthy 
 Living / Dead Living  

Daughter(s)

Your Daughter 1
QuestionResponseComment/Age Affected
 Current age or age at death  9   
 Health Problem
 Healthy 
 Living / Dead Living  

Your Daughter 2
QuestionResponseComment/Age Affected
 Current age or age at death  2.5   
 Health Problem
 Healthy 
 Living / Dead Living  

Your Mother's Father
QuestionResponseComment/Age Affected
 Current age or age at death  80   
 Health Problem
 Stroke - cause of death 80
 Living / Dead Dead  

Your Mother's Mother
QuestionResponseComment/Age Affected
 Current age or age at death  83   
 Health Problem
 Stroke 71
 Living / Dead Living  

Your Father's Father
QuestionResponseComment/Age Affected
 Current age or age at death  84   
 Health Problem
 Stroke - cause of death 84
 Living / Dead Dead  

Your Father's Mother
QuestionResponseComment/Age Affected
 Current age or age at death  83   
 Health Problem
 Lymphoma(ALL-Acute Lymphocytic Lymphoma) 70
 Complication of lymphoma - cause of death 83
 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