Summary Profile

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Donor Number: 0846

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?	No
Allergies (medicines, food, pollens)? If yes, please list substance and reaction caused:	No
CMV IgG Antibody	Positive
CMV IgM Antibody	Negative
Note any comments regarding above items:	N/A

Family Medical History
See list of questions asked here

Your Mother

Question	Response	Comment/Age Affected
Current age or age at death	62
Health Problem	Truck accident
Living / Dead	Dead

Your Father

Question	Response	Comment/Age Affected
Current age or age at death	66
Health Problem	Chronic bronchitis	58
Living / Dead	Living

Brothers

Your Brother 1

Question	Response	Comment/Age Affected
Current age or age at death	38
Health Problem	Healthy
Living / Dead	Living

Your Brother 2

Question	Response	Comment/Age Affected
Current age or age at death	34
Health Problem	Healthy
Living / Dead	Living

Sisters

Your Sister 1

Question	Response	Comment/Age Affected
Current age or age at death	43
Health Problem	Healthy
Living / Dead	Living

Sons

Your Son 1

Question	Response	Comment/Age Affected
Current age or age at death		13
Health Problem	healthy
Living / Dead	Living

Your Mother's Father

Question	Response	Comment/Age Affected
Current age or age at death	49
Health Problem	Died in war
Living / Dead	Dead

Your Mother's Mother

Question	Response	Comment/Age Affected
Current age or age at death	74
Health Problem	Hypertension- stroke	67
Living / Dead	Dead

Your Mother's Sisters 1

Question	Response	Comment/Age Affected
Current age or age at death	70
Health Problem	Healthy
Living / Dead	Living

Your Mother's Brothers 1

Question	Response	Comment/Age Affected
Current age or age at death	68
Health Problem	Lung cancer	65
Living / Dead	Living

Your Father's Father

Question	Response	Comment/Age Affected
Current age or age at death	53
Health Problem	pulmonary tuberculosis	51
Living / Dead	Dead

Your Father's Mother

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

Your Father's Brothers 1

Question	Response	Comment/Age Affected
Current age or age at death	60
Health Problem	Healthy
Living / Dead	Living

Religion:

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