Summary Profile

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Donor Number: 5115

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 - But I eat no meat of any kind (religious reasons)
Do you wear glasses or contact lenses? Are you near or far-sighted?	Yes - Far-sighted
Allergies (medicines, food, pollens)? If yes, please list substance and reaction caused:	No
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	56
Health Problem	Anemia, controlled with iron supplements	50
Living / Dead	Living

Your Father

Question	Response	Comment/Age Affected
Current age or age at death	62
Health Problem	High cholesterol, controlled with medication	45
	High blood pressure, controlled with medication	45
	Diabetes mellitus, controlled with diet modifications	45
	Obesity, no treatment	50
	Asthma, controlled with inhaler	55
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

Your Brother 2

Question	Response	Comment/Age Affected
Current age or age at death	31
Health Problem	Healthy
Living / Dead	Living

Your Brother 3

Question	Response	Comment/Age Affected
Current age or age at death	23
Health Problem	Healthy
Living / Dead	Living

Your Mother's Father

Question	Response	Comment/Age Affected
Current age or age at death	84
Health Problem	Healthy
Living / Dead	Living

Your Mother's Mother

Question	Response	Comment/Age Affected
Current age or age at death	80
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 Father's Father

Question	Response	Comment/Age Affected
Current age or age at death	93
Health Problem	Respiratory failure, no treatment	93
Health Problem	Cause of death: Respiratory failure	93
Living / Dead	Dead

Your Father's Mother

Question	Response	Comment/Age Affected
Current age or age at death	89
Health Problem	Osteoarthritis, controlled with medication	80
	Situational depression, following death of husband, no treatment	84
	Heart failure, no treatment	89
	Cause of death: Heart failure	89
Living / Dead	Dead

Your Father's Sisters 1

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

Your Father's Brothers 1

Question	Response	Comment/Age Affected
Current age or age at death	43
Health Problem	Healthy
	Severe trauma due to car accident, no treatment	43
	Cause of death: Severe trauma	43
Living / Dead	Dead

Religion:

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