Summary Profile

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Donor Number: 5211

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 - Penicillin, Cephalosporins: Cause a rash
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	Migraines (rare), no treatment	54
Living / Dead	Living

Your Father

Question	Response	Comment/Age Affected
Current age or age at death	58
Health Problem	Gallstones, no treatment	55
Living / Dead	Living

Your Mother's Father

Question	Response	Comment/Age Affected
Current age or age at death	83
Health Problem	Diabetes not requiring insulin therapy, managed with diet	65
Living / Dead	Living

Your Mother's Mother

Question	Response	Comment/Age Affected
Current age or age at death	72
Health Problem	Heart attack, fatal, no treatment	72
Health Problem	Cause of death: Heart attack	72
Living / Dead	Dead

Your Mother's Sisters 1

Question	Response	Comment/Age Affected
Current age or age at death	62
Health Problem	Healthy
Living / Dead	Living

Your Mother's Sisters 2

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	80
Health Problem	High blood pressure, no treatment	70
	Heart attack, fatal, no treatment	80
	Cause of death: Heart attack	80
Living / Dead	Dead

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	62
Health Problem	Healthy
Living / Dead	Living

Your Father's Brothers 1

Question	Response	Comment/Age Affected
Current age or age at death	64
Health Problem	Healthy
Living / Dead	Living

Your Father's Brothers 2

Question	Response	Comment/Age Affected
Current age or age at death	60
Health Problem	Healthy
Living / Dead	Living

Religion:

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