Summary Profile

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Donor Number: 4228

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:	Yes - Poison ivy, poison oak, poison sumac: Rash/itching
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	46
Health Problem	High blood pressure, treated with medication and diet modification	41
Living / Dead	Living

Your Father

Question	Response	Comment/Age Affected
Current age or age at death	56
Health Problem	Type 2 Diabetes, treated with insulin	38
Health Problem	High blood pressure, treated with medication and diet modification	45
Living / Dead	Living

Brothers

Your Brother 1

Question	Response	Comment/Age Affected
Current age or age at death	15
Health Problem	Healthy
Living / Dead	Living

Your Mother's Father

Question	Response	Comment/Age Affected
Current age or age at death	65
Health Problem	Type 2 Diabetes, treated with insulin	40
	High blood pressure, treated with medication	50
	Cause of death: Complications of diabetes	65
Living / Dead	Dead

Your Mother's Mother

Question	Response	Comment/Age Affected
Current age or age at death	85
Health Problem	High blood pressure, treated with medication	40
	Stroke, no treatment received	85
	Cause of death: Stroke	85
Living / Dead	Dead

Your Mother's Sisters 1

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

Your Mother's Brothers 1

Question	Response	Comment/Age Affected
Current age or age at death	56
Health Problem	Healthy
Living / Dead	Living

Your Father's Father

Question	Response	Comment/Age Affected
Current age or age at death	70
Health Problem	Stomach cancer, no treatment received	70
Health Problem	Cause of death: Stomach cancer	70
Living / Dead	Dead

Your Father's Mother

Question	Response	Comment/Age Affected
Current age or age at death	85
Health Problem	Breast cancer, no treatment received	85
Health Problem	Cause of death: Breast cancer	85
Living / Dead	Dead

Religion:

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