Summary Profile

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Donor Number: 5160

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	54
Health Problem	Healthy
Living / Dead	Living

Your Father

Question	Response	Comment/Age Affected
Current age or age at death	54
Health Problem	Migraines, treated with over-the-counter medication	13
	Chronic rhinitis, treated with nasal spray, polyps removed	26
	Hernia, treated with surgery	45
	Sarcoidosis, treated with surgery	45
	Gout, managed with diet	48
Living / Dead	Living

Your Mother's Father

Question	Response	Comment/Age Affected
Current age or age at death	82
Health Problem	Stroke, no treatment	75
	Hypertension, controlled with medication	77
	Glaucoma, treated with eye drops	78
Living / Dead	Living

Your Mother's Mother

Question	Response	Comment/Age Affected
Current age or age at death	81
Health Problem	Healthy
Living / Dead	Living

Your Mother's Sisters 1

Question	Response	Comment/Age Affected
Current age or age at death	59
Health Problem	Hypertension, controlled with medication	53
Living / Dead	Living

Your Mother's Brothers 1

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

Your Mother's Brothers 2

Question	Response	Comment/Age Affected
Current age or age at death	50	(fraternal twin)
Health Problem	Lumbar disc herniation, no treatment	45
Living / Dead	Living

Your Father's Father

Question	Response	Comment/Age Affected
Current age or age at death	64
Health Problem	Heart disease, from a bacterial infection (he worked with disease outbreaks), treated with surgery	40
	Stroke, blood clot dislodged, no treatment	64
	Cause of death: Stroke	64
Living / Dead	Dead

Your Father's Mother

Question	Response	Comment/Age Affected
Current age or age at death	84
Health Problem	Hypertension, controlled with medication	70
	Cataracts, treated with surgery	75
	Kidney stone, treated with surgery	75
Living / Dead	Living

Your Father's Brothers 1

Question	Response	Comment/Age Affected
Current age or age at death	58
Health Problem	Healthy
Living / Dead	Living

Religion:

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