Summary Profile

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Donor Number: 4361

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	56
Health Problem	Healthy
Living / Dead	Living

Your Father

Question	Response	Comment/Age Affected
Current age or age at death	55
Health Problem	High cholesterol, treated with medication	45
Living / Dead	Living

Sisters

Your Sister 1

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

Your Mother's Father

Question	Response	Comment/Age Affected
Current age or age at death	80
Health Problem	Broken neck from a fall, treated in hospital with brace and physical therapy	80
Health Problem	Partial loss of vision, resulting from broken neck, no treatment	80
Living / Dead	Living

Your Mother's Mother

Question	Response	Comment/Age Affected
Current age or age at death	65
Health Problem	Miscarriages (three; two in mid-20s, one in mid-30s)
	Lung cancer, smoker, treated with chemotherapy and radiation	65
	Cause of death: Lung cancer	65
Living / Dead	Dead

Your Mother's Sisters 1

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

Your Mother's Brothers 1

Question	Response	Comment/Age Affected
Current age or age at death	50
Health Problem	Diabetes, controlled with diet	40
Health Problem	Kidney stones, passed on their own, treated only with over-the-counter pain medication	45
Living / Dead	Living

Your Mother's Brothers 2

Question	Response	Comment/Age Affected
Current age or age at death	29
Health Problem	Trauma from car crash	29
Health Problem	Cause of death: Trauma	29
Living / Dead	Dead

Your Father's Father

Question	Response	Comment/Age Affected
Current age or age at death	80
Health Problem	Healthy
Living / Dead	Living

Your Father's Mother

Question	Response	Comment/Age Affected
Current age or age at death	80
Health Problem	Healthy
Living / Dead	Living

Religion:

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