Summary Profile

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Donor Number: 4766

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 - Personal choice to stay away from preservatives, milk, white bread and artificial sweets
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	58
Health Problem	Healthy
Living / Dead	Living

Your Father

Question	Response	Comment/Age Affected
Current age or age at death	58
Health Problem	Prostate cancer, treated with surgery	57
Living / Dead	Living

Brothers

Your Brother 1

Question	Response	Comment/Age Affected
Current age or age at death	21
Health Problem	Healthy
Living / Dead	Living

Your Mother's Father

Question	Response	Comment/Age Affected
Current age or age at death	73
Health Problem	High blood pressure, controlled with medication	72
	High cholesterol, controlled with medication	72
	Blood clots, treated with triple bypass surgery	72
	Heart attack, no treatment	73
	Cause of death: Heart attack	73
Living / Dead	Dead

Your Mother's Mother

Question	Response	Comment/Age Affected
Current age or age at death	80
Health Problem	High blood pressure, controlled with medication	80
	High cholesterol, controlled with medication	80
	Iliac aneurysm, treated with stent	80
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 Sisters 2

Question	Response	Comment/Age Affected
Current age or age at death	54
Health Problem	Healthy
Living / Dead	Living

Your Mother's Brothers 1

Question	Response	Comment/Age Affected
Current age or age at death	52
Health Problem	Healthy
Living / Dead	Living

Your Father's Father

Question	Response	Comment/Age Affected
Current age or age at death	81
Health Problem	High blood pressure, controlled with medication	75
	High cholesterol, controlled with medication	75
	Severe trauma due to car accident, no treatment	81
	Cause of death: Severe trauma	81
Living / Dead	Dead

Your Father's Mother

Question	Response	Comment/Age Affected
Current age or age at death	78
Health Problem	Stroke, no treatment	78
Health Problem	Cause of death: Stroke	78
Living / Dead	Dead

Your Father's Sisters 1

Question	Response	Comment/Age Affected
Current age or age at death	54
Health Problem	Kidney stones, treated with ultrasonic therapy	50
Living / Dead	Living

Your Father's Brothers 1

Question	Response	Comment/Age Affected
Current age or age at death	52
Health Problem	Healthy
Living / Dead	Living

Religion:

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