Summary Profile

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Donor Number: 4336

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	Positive
CMV IgM Antibody	Negative
Note any comments regarding above items:	N/A

Family Medical History
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Your Mother

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

Your Father

Question	Response	Comment/Age Affected
Current age or age at death	59
Health Problem	Healthy
Living / Dead	Living

Your Mother's Father

Question	Response	Comment/Age Affected
Current age or age at death	71
Health Problem	Heart attack, fatal, no treatment	71
Health Problem	Cause of death: Heart attack	71
Living / Dead	Dead

Your Mother's Mother

Question	Response	Comment/Age Affected
Current age or age at death	85
Health Problem	High blood pressure, treated with medication	65
Living / Dead	Living

Your Mother's Sisters 1

Question	Response	Comment/Age Affected
Current age or age at death	53
Health Problem	Healthy
Living / Dead	Living

Your Mother's Brothers 1

Question	Response	Comment/Age Affected
Current age or age at death	71
Health Problem	Intestinal infection, treated with antibiotics	71
Health Problem	Cause of death: Complications of intestinal infection	71
Living / Dead	Dead

Your Father's Father

Question	Response	Comment/Age Affected
Current age or age at death	60
Health Problem	Heart attack, fatal, no treatment	60
Health Problem	Cause of death: Heart attack	60
Living / Dead	Dead

Your Father's Mother

Question	Response	Comment/Age Affected
Current age or age at death	68
Health Problem	Kidney failure, no treatment	68
Health Problem	Cause of death: Kidney failure	68
Living / Dead	Dead

Religion:

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