Summary Profile

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Donor Number: 5324

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	67
Health Problem	Miscarriage	36
	Celiac disease, regulated with diet	50
	Depression (after husband died), treated with medication	59
Living / Dead	Living

Your Father

Question	Response	Comment/Age Affected
Current age or age at death	66
Health Problem	High blood pressure, treated with medication	60
	High cholesterol, treated with medication	60
	Stroke, fatal, no treatment	66
	Cause of death: Stroke	66
Living / Dead	Dead

Brothers

Your Brother 1

Question	Response	Comment/Age Affected
Current age or age at death	39	Maternal half brother
Health Problem	Healthy
Living / Dead	Living

Sisters

Your Sister 1

Question	Response	Comment/Age Affected
Current age or age at death	36	Maternal half sister
Health Problem	Healthy
Health Problem	Pinched nerve in neck, treated with surgery	36
Living / Dead	Living

Your Mother's Father

Question	Response	Comment/Age Affected
Current age or age at death	90
Health Problem	Healthy
Health Problem	Cause of death: Heart failure	90
Living / Dead	Dead

Your Mother's Mother

Question	Response	Comment/Age Affected
Current age or age at death	92
Health Problem	Healthy
Health Problem	Cause of death: Heart failure	92
Living / Dead	Dead

Your Mother's Sisters 1

Question	Response	Comment/Age Affected
Current age or age at death	69
Health Problem	Healthy
Living / Dead	Living

Your Mother's Sisters 2

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

Your Mother's Sisters 3

Question	Response	Comment/Age Affected
Current age or age at death	63
Health Problem	Gout, no treatment	61
Living / Dead	Living

Your Father's Father

Question	Response	Comment/Age Affected
Current age or age at death	50
Health Problem	Healthy
	Gastrointestinal infection contracted from drinking river water, not treated	50
	Cause of death: Gastrointestinal infection	50
Living / Dead	Dead

Your Father's Mother

Question	Response	Comment/Age Affected
Current age or age at death	65
Health Problem	Diabetes, treatment unknown, overweight	39
Health Problem	Cause of death: Complications of diabetes	65
Living / Dead	Dead

Your Father's Brothers 1

Question	Response	Comment/Age Affected
Current age or age at death	63
Health Problem	Heart attack, no treatment	63
Health Problem	Cause of death: Heart attack	63
Living / Dead	Dead

Religion:

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