Summary Profile

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Donor Number: 5041

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:	No
CMV IgG Antibody	Negative
CMV IgM Antibody	Negative
Note any comments regarding above items:	N/A

Family Medical History
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Your Mother

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

Your Father

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

Sisters

Your Sister 1

Question	Response	Comment/Age Affected
Current age or age at death	27
Health Problem	Healthy
Living / Dead	Living

Your Sister 2

Question	Response	Comment/Age Affected
Current age or age at death	19	Paternal half sister
Health Problem	Healthy
Living / Dead	Living

Sons

Your Son 1

Question	Response	Comment/Age Affected
Current age or age at death	4
Health Problem	Healthy
Living / Dead	Living

Your Mother's Father

Question	Response	Comment/Age Affected
Current age or age at death	86
Health Problem	Lung cancer (lifelong smoker), treated only for pain management	85
Health Problem	Cause of death: Lung cancer	86
Living / Dead	Dead

Your Mother's Mother

Question	Response	Comment/Age Affected
Current age or age at death	94
Health Problem	Healthy
Living / Dead	Living

Your Mother's Brothers 1

Question	Response	Comment/Age Affected
Current age or age at death	65
Health Problem	Healthy
Living / Dead	Living

Your Father's Father

Question	Response	Comment/Age Affected
Current age or age at death	75
Health Problem	Healthy
Health Problem	Cause of death: Natural causes, died in his sleep	75
Living / Dead	Dead

Your Father's Mother

Question	Response	Comment/Age Affected
Current age or age at death	79
Health Problem	Healthy
	Heart attack, fatal, no treatment	79
	Cause of death: Heart attack	79
Living / Dead	Dead

Religion:

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