Summary Profile

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Donor Number: 2774

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	65
Health Problem	Healthy
Living / Dead	Living

Your Father

Question	Response	Comment/Age Affected
Current age or age at death	69
Health Problem	Healthy
Living / Dead	Living

Sisters

Your Sister 1

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	1.3
Health Problem	Healthy
Living / Dead	Living

Your Mother's Father

Question	Response	Comment/Age Affected
Current age or age at death	82
Health Problem	Alzheimer's disease, treated with medication	80
Health Problem	Cause of death: Shingles, no treatment	82
Living / Dead	Dead

Your Mother's Mother

Question	Response	Comment/Age Affected
Current age or age at death	70
Health Problem	Lung cancer, treated with surgery	50
	Asthma, treated with inhaler	50
	Cause of death: Lung failure	70
Living / Dead	Dead

Your Mother's Sisters 1

Question	Response	Comment/Age Affected
Current age or age at death	63
Health Problem	Breast cancer, treated by mastectomy	50
Living / Dead	Living

Your Father's Father

Question	Response	Comment/Age Affected
Current age or age at death	65
Health Problem	Heart attack, no treatment	65
Health Problem	Cause of death: Heart attack	65
Living / Dead	Dead

Your Father's Mother

Question	Response	Comment/Age Affected
Current age or age at death	35
Health Problem	Cervical cancer, no treatment	35
Health Problem	Cause of death: Cervical cancer	35
Living / Dead	Dead

Your Father's Sisters 1

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

Your Father's Sisters 2

Question	Response	Comment/Age Affected
Current age or age at death	66
Health Problem	Kidney stone, treated with medication	35
Living / Dead	Living

Religion:

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