Summary Profile

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Donor Number: 4429

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:	Yes - Cigarette smoke: Stuffy nose; Seasonal allergies: Stuffy nose and sneezing
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	49
Health Problem	Healthy
Living / Dead	Living

Your Father

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

Your Mother's Father

Question	Response	Comment/Age Affected
Current age or age at death	58
Health Problem	Heart attack, no treatment	58
Health Problem	Cause of death: Heart attack	58
Living / Dead	Dead

Your Mother's Mother

Question	Response	Comment/Age Affected
Current age or age at death	69
Health Problem	Stroke, treated in hospital	69
Health Problem	Cause of death: Stroke	69
Living / Dead	Dead

Your Father's Father

Question	Response	Comment/Age Affected
Current age or age at death	71
Health Problem	Healthy
Living / Dead	Living

Your Father's Mother

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

Your Father's Sisters 1

Question	Response	Comment/Age Affected
Current age or age at death	44
Health Problem	Healthy
Health Problem	Cause of death: Car accident	44
Living / Dead	Dead

Your Father's Brothers 1

Question	Response	Comment/Age Affected
Current age or age at death	45
Health Problem	Healthy
Living / Dead	Living

Religion:

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