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Donor Questionnaire
1
Name of husband/Nombre del esposo
First Name
Last Name
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2
Name of wife/Nombre de la esposa
First Name
Last Name
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3
Blood type and RH of the husband/Grupo sanguíneo del esposo
O
A
B
AB
RH+
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
RH-
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
An input table for Blood type and RH of the husband/Grupo sanguíneo del esposo
RH+
RH-
O
Row 0, Column 0
A
Row 0, Column 1
B
Row 0, Column 2
AB
Row 0, Column 3
O
Row 1, Column 0
A
Row 1, Column 1
B
Row 1, Column 2
AB
Row 1, Column 3
1
of 2
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4
Blood type and RH of the wife/Grupo sanguíneo de la esposa
O
A
B
AB
+
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
-
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
An input table for Blood type and RH of the wife/Grupo sanguíneo de la esposa
+
-
O
Row 0, Column 0
A
Row 0, Column 1
B
Row 0, Column 2
AB
Row 0, Column 3
O
Row 1, Column 0
A
Row 1, Column 1
B
Row 1, Column 2
AB
Row 1, Column 3
1
of 2
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5
Desired hair color of the Donor/Color del pelo deseado de la donante
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6
Desired color tone of the skin of the Donor (only white Caucasians with different color tones)/Tonalidad de la piel deseada (solo raza caucásica blanca con diferentes tonalidades de piel)
please, specify white or light brown/por favor, especifique blanco o moreno claro
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7
Desired height of the Donor: shorter than 165cm, 165-170cm, taller than 170cm/Altura deseada: menor que 165cm, 165-170cm, mayor que 170cm
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8
Education level of the Donor/Nivel educacional de la donante
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9
Add any special remark/Añada algún requerimiento especial
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