Physical
Medical
Family Medical History
Religion
Updates to ProfilePhysical
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Height:
5'10"
(177 cm) |
Weight:
170 lb
(77 kg) |
Eye Color:
Brown
|
Hair:
Brown/
Straight |
Skin Tone:
Light
|
Ancestry:
Caucasian
|
|
Blood Type:
A+
|
Ethnic Background:
Irish/Russian (Jewish)
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Education:
BS/Nursing
|
Occupation:
Registered Nurse
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Interests:
|
Baseball, Flag Football, Reading, Running
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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 - Ciprofloxacin, liver inflammation |
| CMV IgG Antibody | Negative |
| CMV IgM Antibody | Negative |
| Note any comments regarding above items: | N/A |
Family Medical HistorySee list of questions asked here
Your Mother
| Question | Response |
| Current age or age at death | 72 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
High blood pressure
40
Medication
Your Father
| Question | Response |
| Current age or age at death | 71 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Asthma
12
Inhaler
Sisters
Your Sister 1
| Question | Response |
| Current age or age at death | 41 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Your Sister 2
| Question | Response |
| Current age or age at death | 38 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Asthma
12
Inhaler
Your Mother's Father
| Question | Response |
| Current age or age at death | 86 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Natural Causes (specific cause unknown) |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
No diagnosed health problems at time of death
Your Mother's Mother
| Question | Response |
| Current age or age at death | 82 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Breast Cancer |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Breast cancer
78
Chemotherapy
Your Mother's Sisters 1
| Question | Response |
| Current age or age at death | 76 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Your Mother's Sisters 2
| Question | Response |
| Current age or age at death | 68 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Your Mother's Brothers 1
| Question | Response |
| Current age or age at death | 66 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Heart Attack |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
No other diagnosed health problems at time of death
Your Mother's Brothers 2
| Question | Response |
| Current age or age at death | 65 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
High blood pressure
40
Medication
Your Father's Father
| Question | Response |
| Current age or age at death | 40 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Drowning accident |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Other
No diagnosed health problems at time of death
Your Father's Mother
| Question | Response |
| Current age or age at death | 84 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Dementia |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Dementia or degenerative disorders
81
Nursing care
Your Father's Sisters 1
| Question | Response |
| Current age or age at death | 74 |
| Living / Dead | Living |
| Cause of death and any treatment prior to death | N/A |
Health Problems
Healthy
Your Father's Sisters 2
| Question | Response |
| Current age or age at death | 50 |
| Living / Dead | Dead |
| Cause of death and any treatment prior to death | Lung Cancer (smoker) |
Health Problems
Disease
Age Diagnosed
Treatment For Condition
Lung cancer
48
No treatment
Religion:
| Faith | Jewish |
| Denomination | Non-denominational |
Updates to Profile
| Update Available | N/A |
| Updates - Personal | N/A |
| Updates - Medical | N/A |
| Updates - Family Medical History | N/A |