Summary Profile

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Número do Doador: 1130-CLI

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	Negative
CMV IgM Antibody	Negative
Note any comments regarding above items:	N/A

Family Medical History
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Your Mother

Question	Response	Comment/Age Affected
Current age or age at death	67
Health Problem	Healthy
Living / Dead	Living

Your Father

Question	Response	Comment/Age Affected
Current age or age at death	67
Health Problem	Diabetes mellitus requiring insulin	50
	Bacterial menengitis	57
	First knee replacement	55
	Second knee replacement	65
Living / Dead	Living

Brothers

Your Brother 1

Question	Response	Comment/Age Affected
Current age or age at death	41
Health Problem	Healthy
Living / Dead	Living

Your Brother 2

Question	Response	Comment/Age Affected
Current age or age at death	39
Health Problem	Healthy
Living / Dead	Living

Daughters

Your Daughter 1

Question	Response	Comment/Age Affected
Current age or age at death	5
Health Problem	Broken arm from accident	5
Living / Dead	Living

Your Mother's Father

Question	Response	Comment/Age Affected
Current age or age at death	73
Health Problem	Brain tumor	72
Living / Dead	Dead

Your Mother's Mother

Question	Response	Comment/Age Affected
Current age or age at death	96
Health Problem	Arthritis	70
	Moderate hearing loss	80
	Breast cancer	94
Living / Dead	Living

Your Mother's Brothers 1

Question	Response	Comment/Age Affected
Current age or age at death	63
Health Problem	Healthy
Living / Dead	Living

Your Father's Father

Question	Response	Comment/Age Affected
Current age or age at death	85
Health Problem	Diabetes mellitus requiring insulin	50
Health Problem	Parkinson's Disease	60
Living / Dead	Dead

Your Father's Mother

Question	Response	Comment/Age Affected
Current age or age at death	85
Health Problem	Cause of death: Car accident	85
Living / Dead	Dead

Your Father's Sisters 1

Question	Response	Comment/Age Affected
Current age or age at death	66
Health Problem	Toxic shock syndrome- fingers amputated	46
Health Problem	Cause of death: Unknown	66
Living / Dead	Dead

Religion:

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