Summary Profile

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Donor Number: 4070

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 - Seasonal allergies: Cause nasal inflammation
CMV IgG Antibody	Negative
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	57
Health Problem	Healthy
Living / Dead	Living

Your Father

Question	Response	Comment/Age Affected
Current age or age at death	57
Health Problem	Hay fever, treated with allergy shots	18
Living / Dead	Living

Sisters

Your Sister 1

Question	Response	Comment/Age Affected
Current age or age at death	28
Health Problem	Asthma (as a child), treated with an inhaler	6
Living / Dead	Living

Your Sister 2

Question	Response	Comment/Age Affected
Current age or age at death	25
Health Problem	Scoliosis, treated with exercise	13
Health Problem	Anorexia, bulimia, treated with counseling	14
Living / Dead	Living

Your Mother's Father

Question	Response	Comment/Age Affected
Current age or age at death	87
Health Problem	Age-related heart disease, treated with heart valve replacement	84
Health Problem	Macular degeneration, treated with medication	87
Living / Dead	Living

Your Mother's Mother

Question	Response	Comment/Age Affected
Current age or age at death	75
Health Problem	Stroke, treated with medication and two weeks of rehabilitation (she was a heavy smoker)	75
	Heart attack, suffered two weeks after the stroke	75
	Cause of death: Heart attack	75
Living / Dead	Dead

Your Mother's Sisters 1

Question	Response	Comment/Age Affected
Current age or age at death	60
Health Problem	Brain tumor, pre-cancerous, treated with surgery and radiation	60
Living / Dead	Living

Your Mother's Sisters 2

Question	Response	Comment/Age Affected
Current age or age at death	54
Health Problem	Healthy
Living / Dead	Living

Your Father's Father

Question	Response	Comment/Age Affected
Current age or age at death	82
Health Problem	Healthy
Living / Dead	Living

Your Father's Mother

Question	Response	Comment/Age Affected
Current age or age at death	82
Health Problem	Healthy
Living / Dead	Living

Your Father's Sisters 1

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

Your Father's Brothers 1

Question	Response	Comment/Age Affected
Current age or age at death	54
Health Problem	Healthy
Living / Dead	Living

Religion:

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