Summary Profile

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Donor Number: 4839

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:	Yes - Cat hair: Itchy eyes; Ragweed: Sneezing, runny nose
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	44
Health Problem	Healthy
Living / Dead	Living

Your Father

Question	Response	Comment/Age Affected
Current age or age at death	45
Health Problem	Healthy
Living / Dead	Living

Brothers

Your Brother 1

Question	Response	Comment/Age Affected
Current age or age at death	27	Maternal half brother
Health Problem	Healthy
Living / Dead	Living

Sisters

Your Sister 1

Question	Response	Comment/Age Affected
Current age or age at death	13
Health Problem	Irritable Bowel Syndrome, controlled with diet modifications	9
Living / Dead	Living

Your Mother's Father

Question	Response	Comment/Age Affected
Current age or age at death	66
Health Problem	Born without thumb on left hand, no treatment
Health Problem	High blood pressure, controlled with diet modifications	60
Living / Dead	Living

Your Mother's Mother

Question	Response	Comment/Age Affected
Current age or age at death	31
Health Problem	Severe trauma due to motorcycle accident, no treatment	31
Health Problem	Cause of death: Severe trauma	31
Living / Dead	Dead

Your Mother's Sisters 1

Question	Response	Comment/Age Affected
Current age or age at death	32
Health Problem	Rheumatoid arthritis, managed with medication	31
Living / Dead	Living

Your Mother's Brothers 1

Question	Response	Comment/Age Affected
Current age or age at death	28
Health Problem	Healthy
Living / Dead	Living

Your Mother's Brothers 2

Question	Response	Comment/Age Affected
Current age or age at death	21
Health Problem	Healthy
Living / Dead	Living

Your Father's Father

Question	Response	Comment/Age Affected
Current age or age at death	64
Health Problem	Heart attack, treated with surgery and medication	61
Living / Dead	Living

Your Father's Mother

Question	Response	Comment/Age Affected
Current age or age at death	62
Health Problem	Severe trauma due to car accident, no treatment	62
Health Problem	Cause of death: Severe trauma	62
Living / Dead	Dead

Your Father's Sisters 1

Question	Response	Comment/Age Affected
Current age or age at death	40
Health Problem	Miscarriage, no treatment, 2 successful childbirths following	35
Living / Dead	Living

Religion:

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