Summary Profile

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Donor Number: 4157

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	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	56
Health Problem	Kidney stones, treated with ultrasound to break up stones	40
Living / Dead	Living

Your Father

Question	Response	Comment/Age Affected
Current age or age at death	66
Health Problem	Hay fever, treated with medication	20
Health Problem	High cholesterol, controlled with diet and exercise until age 65; now controlled with medication	35
Living / Dead	Living

Sisters

Your Sister 1

Question	Response	Comment/Age Affected
Current age or age at death	22
Health Problem	Acne, treated with over-the-counter medication	12
Living / Dead	Living

Your Sister 2

Question	Response	Comment/Age Affected
Current age or age at death	20
Health Problem	Acne, treated with over-the-counter medication	12
Health Problem	Hayfever, treated with medication	20
Living / Dead	Living

Your Mother's Father

Question	Response	Comment/Age Affected
Current age or age at death	84
Health Problem	Heart attack, treated with medication and diet control	55
	Pneumonia, no medication or treatment received	84
	Cause of death: Pneumonia	84
Living / Dead	Dead

Your Mother's Mother

Question	Response	Comment/Age Affected
Current age or age at death	90
Health Problem	Stomach cancer, successfully treated with surgery	70
Health Problem	Osteoporosis, treated with calcium pills	79
Living / Dead	Living

Your Mother's Sisters 1

Question	Response	Comment/Age Affected
Current age or age at death	61
Health Problem	Healthy
Living / Dead	Living

Your Mother's Brothers 1

Question	Response	Comment/Age Affected
Current age or age at death	59
Health Problem	Healthy
Living / Dead	Living

Your Father's Father

Question	Response	Comment/Age Affected
Current age or age at death	67
Health Problem	Excessive plaque in lungs (job-related), no treatment or medication received	66
Health Problem	Cause of death: Dehydration due to excessive plaque in lungs	67
Living / Dead	Dead

Your Father's Mother

Question	Response	Comment/Age Affected
Current age or age at death	84
Health Problem	Breast cancer, successfully treated with surgery and medication	79
	Alzheimer's Disease, no medication or treatment received	83
	Cause of death: Alzheimer's Disease	84
Living / Dead	Dead

Your Father's Brothers 1

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

Your Father's Brothers 2

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

Religion:

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