Summary Profile

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Donor Number: 4705

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 - (I try to avoid foods that are high in saturated fats, cholesterol, sodium, and sugar)
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:	Yes - Dust and pollen: Runny nose, itchy eyes
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	49
Health Problem	Healthy
Living / Dead	Living

Your Father

Question	Response	Comment/Age Affected
Current age or age at death	51
Health Problem	High cholesterol, treated with diet and exercise	45
Living / Dead	Living

Brothers

Your Brother 1

Question	Response	Comment/Age Affected
Current age or age at death	19
Health Problem	Healthy
Living / Dead	Living

Sisters

Your Sister 1

Question	Response	Comment/Age Affected
Current age or age at death	1.5	(Half-sister)
Health Problem	Healthy
Living / Dead	Living

Your Mother's Father

Question	Response	Comment/Age Affected
Current age or age at death	80
Health Problem	Healthy
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	47
Health Problem	Ovarian cyst (benign), treated with surgery	47
Living / Dead	Living

Your Mother's Brothers 1

Question	Response	Comment/Age Affected
Current age or age at death	52
Health Problem	Healthy
Living / Dead	Living

Your Mother's Brothers 2

Question	Response	Comment/Age Affected
Current age or age at death	44
Health Problem	Healthy
Living / Dead	Living

Your Father's Father

Question	Response	Comment/Age Affected
Current age or age at death	85
Health Problem	High blood pressure (smoker), treatment (if any) unknown	75
	Diabetes, treated with diet	75
	Lung cancer, no treatment	83
	Cause of death: Lung cancer	85
Living / Dead	Dead

Your Father's Mother

Question	Response	Comment/Age Affected
Current age or age at death	82
Health Problem	Hypoglycemia, treated with diet	72
	High blood pressure, treated with diet	75
	Glaucoma, no treatment	75
Living / Dead	Living

Your Father's Brothers 1

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

Religion:

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