Summary Profile

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Donor Number: 5402

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	Negative
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	51
Health Problem	Seasonal allergies, treated with over-the-counter medication	30
Health Problem	High cholesterol, treated with medication	51
Living / Dead	Living

Your Father

Question	Response	Comment/Age Affected
Current age or age at death	61
Health Problem	High blood pressure, treated with medication	50
	Vasculitis, hospitalized for 3-4 months, treated with chemotherapy	50
	Poor kidney function (as a result of vasculitis treatment), treated with medication	55
Living / Dead	Living

Sisters

Your Sister 1

Question	Response	Comment/Age Affected
Current age or age at death	25
Health Problem	Healthy
Living / Dead	Living

Your Mother's Father

Question	Response	Comment/Age Affected
Current age or age at death	63
Health Problem	Kidney cancer, no treatment	61
Health Problem	Cause of death: Kidney cancer	63
Living / Dead	Dead

Your Mother's Mother

Question	Response	Comment/Age Affected
Current age or age at death	66
Health Problem	High cholesterol, treated with medication	50
Living / Dead	Living

Your Mother's Brothers 1

Question	Response	Comment/Age Affected
Current age or age at death	46
Health Problem	Healthy
Living / Dead	Living

Your Father's Father

Question	Response	Comment/Age Affected
Current age or age at death	67
Health Problem	Lung cancer (heavy smoker), no treatment	65
Health Problem	Cause of death: Lung cancer	67
Living / Dead	Dead

Your Father's Mother

Question	Response	Comment/Age Affected
Current age or age at death	85
Health Problem	Healthy
Health Problem	Cause of death: Heart failure	85
Living / Dead	Dead

Your Father's Sisters 1

Question	Response	Comment/Age Affected
Current age or age at death	70
Health Problem	Healthy
Living / Dead	Living

Your Father's Sisters 2

Question	Response	Comment/Age Affected
Current age or age at death	68
Health Problem	Breast cancer, treated with chemotherapy, she has made a full recovery	58
Living / Dead	Living

Religion:

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