Summary Profile

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Donor Number: 5314

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
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	52
Health Problem	Migraines, treatment (if any) unknown	40
	High blood pressure, controlled with medication	45
	Brain aneurysm, no treatment	52
	Cause of death: Brain aneurysm	52
Living / Dead	Dead

Your Mother's Father

Question	Response	Comment/Age Affected
Current age or age at death	55
Health Problem	Heart attack, no treatment	55
Health Problem	Cause of death: Heart attack	55
Living / Dead	Dead

Your Mother's Mother

Question	Response	Comment/Age Affected
Current age or age at death	78
Health Problem	Pancreatic cancer, no treatment	78
Health Problem	Cause of death: Pancreatic cancer	78
Living / Dead	Dead

Your Mother's Brothers 1

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

Your Mother's Brothers 2

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

Your Mother's Brothers 3

Question	Response	Comment/Age Affected
Current age or age at death	53
Health Problem	Partial hearing loss, no known cause, treated with cochlear implant at age 8
Living / Dead	Living

Your Father's Father

Question	Response	Comment/Age Affected
Current age or age at death	56
Health Problem	Undiagnosed lung disease (smoker), treatment (if any) unknown	55
Health Problem	Cause of death: Complications from lung disease	56
Living / Dead	Dead

Your Father's Mother

Question	Response	Comment/Age Affected
Current age or age at death	81
Health Problem	Diabetes mellitus requiring insulin therapy	71
Living / Dead	Living

Your Father's Sisters 1

Question	Response	Comment/Age Affected
Current age or age at death	60
Health Problem	Migraines, treatment (if any) unknown	40
Living / Dead	Living

Your Father's Brothers 1

Question	Response	Comment/Age Affected
Current age or age at death	56
Health Problem	Healthy
Living / Dead	Living

Your Father's Brothers 2

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

Religion:

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