Summary Profile

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Donor Number: 4822

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	61
Health Problem	Cataract, treated with surgery	60
Living / Dead	Living

Your Father

Question	Response	Comment/Age Affected
Current age or age at death	65
Health Problem	Healthy
Living / Dead	Living

Brothers

Your Brother 1

Question	Response	Comment/Age Affected
Current age or age at death	37
Health Problem	Healthy
Living / Dead	Living

Sons

Your Son 1

Question	Response	Comment/Age Affected
Current age or age at death	5
Health Problem	Healthy
Living / Dead	Living

Your Mother's Father

Question	Response	Comment/Age Affected
Current age or age at death	44
Health Problem	Trauma due to combat in WWII, no treatment	44
Health Problem	Cause of death: Trauma	44
Living / Dead	Dead

Your Mother's Mother

Question	Response	Comment/Age Affected
Current age or age at death	52
Health Problem	Heart attack, no treatment	52
Health Problem	Cause of death: Heart attack	52
Living / Dead	Dead

Your Mother's Sisters 1

Question	Response	Comment/Age Affected
Current age or age at death	52
Health Problem	Stage 4 melanoma of the eye, no treatment	52
Health Problem	Cause of death: Melanoma of the eye	52
Living / Dead	Dead

Your Mother's Brothers 1

Question	Response	Comment/Age Affected
Current age or age at death	65
Health Problem	Healthy
Living / Dead	Living

Your Father's Father

Question	Response	Comment/Age Affected
Current age or age at death	88
Health Problem	Heart failure, no treatment	88
Health Problem	Cause of death: Heart failure	88
Living / Dead	Dead

Your Father's Mother

Question	Response	Comment/Age Affected
Current age or age at death	88
Health Problem	Healthy
Living / Dead	Living

Your Father's Brothers 1

Question	Response	Comment/Age Affected
Current age or age at death	67
Health Problem	Healthy
Living / Dead	Living

Your Father's Brothers 2

Question	Response	Comment/Age Affected
Current age or age at death	55
Health Problem	Healthy
Living / Dead	Living

Religion:

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