Summary Profile

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Donor Number: 4950

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 - Pollen: Causes sneezing, running nose, itchy eyes
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	52
Health Problem	Deviated septum, since birth, no treatment
Living / Dead	Living

Your Father

Question	Response	Comment/Age Affected
Current age or age at death	55
Health Problem	High blood pressure, treated with medication	45
	Osteoarthritis, no treatment	45
	Type II Diabetes, managed with diet	53
Living / Dead	Living

Sisters

Your Sister 1

Question	Response	Comment/Age Affected
Current age or age at death	22
Health Problem	Healthy
Living / Dead	Living

Your Mother's Father

Question	Response	Comment/Age Affected
Current age or age at death	88
Health Problem	Heart attack, treated in hospital	81
Health Problem	Macular degeneration, formerly treated with injections, no current treatment	85
Living / Dead	Living

Your Mother's Mother

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

Your Mother's Brothers 1

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

Your Mother's Brothers 2

Question	Response	Comment/Age Affected
Current age or age at death	44
Health Problem	Healthy
Living / Dead	Living

Your Father's Father

Question	Response	Comment/Age Affected
Current age or age at death	80
Health Problem	Laryngeal cancer (smoker), treated with tracheotomy	62
Living / Dead	Living

Your Father's Mother

Question	Response	Comment/Age Affected
Current age or age at death	80
Health Problem	High blood pressure, no treatment	45
	Osteoarthritis, no treatment	45
	Pancreatic cancer, no treatment	80
	Cause of death: Pancreatic cancer	80
Living / Dead	Dead

Your Father's Brothers 1

Question	Response	Comment/Age Affected
Current age or age at death	63
Health Problem	Healthy
Living / Dead	Living

Religion:

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