Summary Profile

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Donor Number: 4375

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	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	62
Health Problem	High blood pressure, treated with medication	55
Living / Dead	Living

Your Father

Question	Response	Comment/Age Affected
Current age or age at death	62
Health Problem	High cholesterol, treated with medication	58
Living / Dead	Living

Brothers

Your Brother 1

Question	Response	Comment/Age Affected
Current age or age at death	33
Health Problem	Healthy
Living / Dead	Living

Sisters

Your Sister 1

Question	Response	Comment/Age Affected
Current age or age at death	30
Health Problem	Healthy
Living / Dead	Living

Your Mother's Father

Question	Response	Comment/Age Affected
Current age or age at death	85
Health Problem	Coronary artery disease, treated with exercise and diet change	63
Health Problem	Cause of death: Died during heart bypass surgery	85
Living / Dead	Dead

Your Mother's Mother

Question	Response	Comment/Age Affected
Current age or age at death	88
Health Problem	Cataract, treated with surgery	70
Living / Dead	Living

Your Mother's Brothers 1

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

Your Father's Father

Question	Response	Comment/Age Affected
Current age or age at death	87
Health Problem	Heart disease, treated with medication	84
Health Problem	Cause of death: Natural causes, died in his sleep	87
Living / Dead	Dead

Your Father's Mother

Question	Response	Comment/Age Affected
Current age or age at death	87
Health Problem	Healthy
Living / Dead	Living

Your Father's Sisters 1

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

Your Father's Brothers 1

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

Religion:

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