Summary Profile

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Donor Number: 5318

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	42
Health Problem	Scoliosis, mild, no treatment necessary, does not affect physical activity
Living / Dead	Living

Your Father

Question	Response	Comment/Age Affected
Current age or age at death	41
Health Problem	Healthy
Living / Dead	Living

Your Mother's Father

Question	Response	Comment/Age Affected
Current age or age at death	72
Health Problem	High cholesterol, treated with medication	60
	Cataracts, no treatment	72
	Ruptured disc, no treatment, followed by rapid decline in health	72
	Cause of death: Heart failure	72
Living / Dead	Dead

Your Mother's Mother

Question	Response	Comment/Age Affected
Current age or age at death	70
Health Problem	High cholesterol, treated with medication	60
	Type II diabetes, treats with insulin	65
	Chronic obstructive pulmonary disease, treats with sleep mask	65
Living / Dead	Living

Your Father's Father

Question	Response	Comment/Age Affected
Current age or age at death	72
Health Problem	Dementia, treated in assisted care	71
Living / Dead	Living

Your Father's Mother

Question	Response	Comment/Age Affected
Current age or age at death	64
Health Problem	Smoking-related lung disease (unsure if it was COPD or emphysema), treated with oxygen	55
Health Problem	Cause of death: Complications of lung disease	64
Living / Dead	Dead

Your Father's Sisters 1

Question	Response	Comment/Age Affected
Current age or age at death	50
Health Problem	Healthy
Living / Dead	Living

Your Father's Sisters 2

Question	Response	Comment/Age Affected
Current age or age at death	49
Health Problem	Healthy
Living / Dead	Living

Your Father's Sisters 3

Question	Response	Comment/Age Affected
Current age or age at death	47
Health Problem	Healthy
Living / Dead	Living

Your Father's Sisters 4

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

Your Father's Brothers 1

Question	Response	Comment/Age Affected
Current age or age at death	43
Health Problem	Healthy
Living / Dead	Living

Religion:

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