Summary Profile

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Donor Number: 4072

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 - Slightly near-sighted
Allergies (medicines, food, pollens)? If yes, please list substance and reaction caused:	Yes - Penicillin: Causes rash
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	52
Health Problem	Miscarriage	28
Living / Dead	Living

Your Father

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

Brothers

Your Brother 1

Question	Response	Comment/Age Affected
Current age or age at death	25
Health Problem	Healthy
Living / Dead	Living

Your Mother's Father

Question	Response	Comment/Age Affected
Current age or age at death	84
Health Problem	Hearing problem, treated with hearing aide	75
Health Problem	Spinal fractures due to advanced age, treated with surgery	83
Living / Dead	Living

Your Mother's Mother

Question	Response	Comment/Age Affected
Current age or age at death	82
Health Problem	Cataracts, treated with eyeglasses	81
Living / Dead	Living

Your Mother's Sisters 1

Question	Response	Comment/Age Affected
Current age or age at death	57
Health Problem	Healthy
Living / Dead	Living

Your Father's Father

Question	Response	Comment/Age Affected
Current age or age at death	85
Health Problem	Healthy
Living / Dead	Living

Your Father's Mother

Question	Response	Comment/Age Affected
Current age or age at death	78
Health Problem	High blood pressure, treated with medication, diagnosed in her 60s	60
	Lung problems from smoking, treated with oxygen	70
	Atrial fibrillation, treated with medication	70
	Cause of death: Heart failure	78
Living / Dead	Dead

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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