Summary Profile

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Donor Number: 4999

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	70
Health Problem	Healthy
Living / Dead	Living

Your Father

Question	Response	Comment/Age Affected
Current age or age at death	67
Health Problem	High blood pressure, controlled with medication	58
	Type II diabetes, controlled with diet change and medication	63
	Knee replacement surgery, due to long employment in the military and construction	65
	Partial blockage of an artery in back, treated with a stent	65
Living / Dead	Living

Brothers

Your Brother 1

Question	Response	Comment/Age Affected
Current age or age at death	38
Health Problem	Healthy
Living / Dead	Living

Your Mother's Father

Question	Response	Comment/Age Affected
Current age or age at death	40
Health Problem	Heart attack, no risk factors, hospitalized for a few days before his death	40
Health Problem	Cause of death: Heart attack	40
Living / Dead	Dead

Your Mother's Mother

Question	Response	Comment/Age Affected
Current age or age at death	95
Health Problem	Macular degeneration, no treatment	80
	Mini stroke, in her early 80s, treated with medication
	Cause of death: Heart failure	95
Living / Dead	Dead

Your Mother's Sisters 1

Question	Response	Comment/Age Affected
Current age or age at death	72
Health Problem	Healthy
Living / Dead	Living

Your Mother's Sisters 2

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

Your Mother's Brothers 1

Question	Response	Comment/Age Affected
Current age or age at death	75
Health Problem	Healthy
Living / Dead	Living

Your Mother's Brothers 2

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	87
Health Problem	Colon cancer, discovered after sudden death	87
Health Problem	Cause of death: Colon cancer	87
Living / Dead	Dead

Your Father's Mother

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

Your Father's Brothers 1

Question	Response	Comment/Age Affected
Current age or age at death	69
Health Problem	Stroke, treated briefly in hospital	69
	High blood pressure, discovered after stroke	69
	Cause of death: Stroke	69
Living / Dead	Dead

Religion:

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