Summary Profile

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Donor Number: 4957

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 - Sulfa medicine: Causes hives
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	55
Health Problem	Healthy
Living / Dead	Living

Your Father

Question	Response	Comment/Age Affected
Current age or age at death	58
Health Problem	High cholesterol, in his early 50s, treated with medication
Health Problem	Gallstones, treated with removal of gallbladder	57
Living / Dead	Living

Sisters

Your Sister 1

Question	Response	Comment/Age Affected
Current age or age at death	25
Health Problem	Healthy
Living / Dead	Living

Sons

Your Son 1

Question	Response	Comment/Age Affected
Current age or age at death	2
Health Problem	Healthy
Living / Dead	Living

Your Mother's Father

Question	Response	Comment/Age Affected
Current age or age at death	60
Health Problem	Heart attack (was a smoker when younger), treated in hospital	35
	Heart attack, treated in hospital	51
	Heart attack, fatal, no treatment	52
	Cause of death: Heart attack	52
Living / Dead	Dead

Your Mother's Mother

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

Your Mother's Sisters 1

Question	Response	Comment/Age Affected
Current age or age at death	57
Health Problem	Healthy
Living / Dead	Living

Your Mother's Brothers 1

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

Your Mother's Brothers 2

Question	Response	Comment/Age Affected
Current age or age at death	47
Health Problem	High blood pressure, treated with medication	40
	High cholesterol, treated with medication	40
	Heart attack, treated with cardiac catheterization	47
	Cause of death: Heart attack	47
Living / Dead	Dead

Your Father's Father

Question	Response	Comment/Age Affected
Current age or age at death	60
Health Problem	Congestive heart failure, in his late 50s, treated with surgery
Health Problem	Cause of death: Congestive heart failure	60
Living / Dead	Dead

Your Father's Mother

Question	Response	Comment/Age Affected
Current age or age at death	99
Health Problem	Congestive heart failure, no treatment	98
Health Problem	Cause of death: Natural causes	99
Living / Dead	Dead

Your Father's Brothers 1

Question	Response	Comment/Age Affected
Current age or age at death	57
Health Problem	Healthy
Living / Dead	Living

Religion:

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