Summary Profile

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Donor Number: 5124

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 - Pet (cat and dog) dander: Causes sneezing, blotchy face (mild reaction)
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	57
Health Problem	Healthy
Living / Dead	Living

Your Father

Question	Response	Comment/Age Affected
Current age or age at death	62
Health Problem	Healthy
Living / Dead	Living

Your Mother's Father

Question	Response	Comment/Age Affected
Current age or age at death	55
Health Problem	Healthy
	Severe trauma due to car accident, no treatment	55
	Cause of death: Severe trauma	55
Living / Dead	Dead

Your Mother's Mother

Question	Response	Comment/Age Affected
Current age or age at death	51
Health Problem	Healthy
	Severe trauma due to car accident, no treatment	51
	Cause of death: Severe trauma	51
Living / Dead	Dead

Your Mother's Sisters 1

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

Your Father's Father

Question	Response	Comment/Age Affected
Current age or age at death	91
Health Problem	Heart attack, no treatment	91
Health Problem	Cause of death: Heart attack	91
Living / Dead	Dead

Your Father's Mother

Question	Response	Comment/Age Affected
Current age or age at death	85
Health Problem	Healthy
Living / Dead	Living

Your Father's Sisters 1

Question	Response	Comment/Age Affected
Current age or age at death	61
Health Problem	Lung cancer, attempted treatment with surgery	61
Health Problem	Cause of death: Complications from surgery to treat lung cancer (died during procedure)	61
Living / Dead	Dead

Your Father's Sisters 2

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

Religion:

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