art clinic upitnik

Vrsta donora/Type of donor

Lokalni / Local

Putujući / Traveling

Ime: / Name:

Prezime: / Last name:

Datum rođenja / Date of birth:

Broj pasoša / Passport number:

Krvna grupa / Blood type:

Visina (u cm) / Height (in cm):

Težina (u kg) / Weight (in kg):

BMI:

Da li ste usvojeni? / Are you adopted?

Da / Yes

Ne / No

Da li ste spremni da putujete? / Are you willing to travel?

Da / Yes

Ne / No

Rasa / Race:

Bela / White

Crna / Black

Azijska / Asian

Latinoamerička / Hispanic or Latino

Mešovita / Mixed

Drugo / Other:

Etnička pripadnost / Ethnicity:

Horoskopski znak / Zodiac Sign:

Ovan / Aries

Bik / Taurus

Blizanci / Gemini

Rak / Cancer

Lav / Leo

Devica / Virgo

Vaga / Libra

Škorpija / Scorpio

Strelac / Sagittarius

Jarac / Capricorn

Vodolija / Aquarius

Ribe / Pisces

Boja očiju / Eye Color:

Plava / Blue

Zelena / Green

Smeđa / Brown

Drugo / Other:

Boja kose / Hair Color:

Plava / Blonde

Smeđa / Brown

Crna / Black

Drugo / Other:

Tip kose / Hair Type:

Prava / Straight

Talasasta / Wavy

Kovrdžava / Curly

Desnorukost/Levorukost / Right-handed or Left-handed:

Desnoruka / Right-handed

Levoruka / Left-handed

Obe ruke podjednako koristi / Ambidextrous

Boja kože / Skin Tone:

Svetla / Fair

Srednje svetla / Light-medium

Maslinasta / Olive

Tamnija / Dark

Veličina odeće / Clothing Size:

Broj cipela / Shoe Size:

Oblik lica / Face Shape:

Okruglo / Round

Ovalno / Oval

Srcoliko / Heart-shaped

Kvadratno / Square

Dugo / Long

Veličina nosa / Nose Size:

Mali / Small

Srednji / Medium

Veliki / Large

Oblik nosa / Nose Shape:

Pravi / Straight

Rimski / Roman

Dugmićasti / Button

Širok / Wide

Kukast / Hooked

Pegice / Freckles:

Da / Yes

Ne / No

Veličina usana / Lip Size:

Tanke / Thin

Srednje / Medium

Pune / Full

Širina usana / Lip Width:

Uske / Narrow

Srednje / Medium

Široke / Wide

Bračni status / Marital Status:

Neoženjena / Single

Udata / Married

Razvedena / Divorced

U vezi / In a relationship

Udovica / Widowed

Broj dece / Number of Children

Nemam dece / No children

Starost deteta/dece / Age of Child(ren):

Pol deteta/dece / Gender of Child(ren):

Muško / Male

Žensko / Female

Da li ste vegetarijanac? / Are you a vegetarian?

Da / Yes

Ne / No

Da li vozite automobil? / Do you drive a car?

Da / Yes

Ne / No

Da li vozite bicikl? / Do you ride a bicycle?

Da / Yes

Ne / No

Da li svirate neki instrument? Ako da, koji? / Do you play a musical instrument? If yes, which one?

Ne / No

Da / Yes

Koji? / Which one?

Omiljena boja / Favorite Color:

Omiljeno jelo / Favorite Food:

Omiljeni praznik / Favorite Holiday:

Omiljeni film / Favorite Movie:

Omiljeni muzički žanr / Favorite Music Genre:

Pop

Rock

Klasična / Classical

Jazz

Hip-hop

Elektronska / Electronic

Drugo / Other:

Omiljena životinja / Favorite Animal:

Omiljeno doba godine / Favorite Season:

Proleće / Spring

Leto / Summer

Jesen / Autumn

Zima / Winter

Omiljeni brend automobila / Favorite Car Brand:

Hobiji / Hobbies:

Veštine i talenti / Skills and Talents:

Sportske aktivnosti / Sports Activities:

Trčanje / Running

Plivanje / Swimming

Biciklizam / Cycling

Joga / Yoga

Fitnes / Fitness

Drugo / Other:

Putovanja / Travel Experience:

Nikad nisam putovala van svoje zemlje / Never traveled abroad

Putovala sam u nekoliko zemalja / Traveled to a few countries

Često putujem / Travel frequently

Tip razmišljanja / Type of Thinking:

Kreativno / Creative

Analitičko / Analytical

Logičko / Logical

Intuitivno / Intuitive

Drugo / Other:

Nivo obrazovanja / Level of Education:

Osnovna škola / Elementary School

Srednja škola / High School

Viša škola / Associate Degree

Fakultet / Bachelor’s Degree

Master / Master’s Degree

Doktorat / PhD

Oblast studiranja / Field of Study:

Prirodne nauke / Natural Sciences

Društvene nauke / Social Sciences

Humanističke nauke / Humanities

Tehničke nauke / Engineering & Technology

Medicina / Medicine

Ekonomija i menadžment / Business & Economics

Umetnost / Arts

Drugo / Other:

Završeni nivo obrazovanja / Completed Level of Education:

Nezavršeno obrazovanje / Incomplete Education

Završena škola / Completed Degree

Omiljeni predmeti u školi / Favorite Subjects in School:

Matematika / Mathematics

Fizika / Physics

Hemija / Chemistry

Biologija / Biology

Književnost / Literature

Istorija / History

Geografija / Geography

Likovna umetnost / Art

Muzika / Music

Fizičko vaspitanje / Physical Education

Strani jezici / Foreign Languages

Drugo / Other:

Trenutna profesija / Current Profession:

Sertifikati / Certifications:

Nemam sertifikate / No certifications

Imam sertifikate / I have certifications

Koji sertifikat? / Which ones?

Jezici koje govorite / Languages Spoken:

Srpski / Serbian

Engleski / English

Nemački / German

Francuski / French

Španski / Spanish

Italijanski / Italian

Ruski / Russian

Kineski / Chinese

Drugi / Other:

Godina rođenja majke / Mother’s Year of Birth:

Da li je majka živa? / Is your mother alive?

Da / Yes

Ne / No

Godina smrti majke / Mother’s Year of Death

Uzrok smrti majke / Mother’s Cause of Death:

Boja očiju majke / Mother’s Eye Color:

Plava / Blue

Zelena / Green

Smeđa / Brown

Drugo / Other:

Boja kose majke / Mother’s Hair Color:

Plava / Blonde

Smeđa / Brown

Crna / Black

Drugo / Other:

Težina majke (kg) / Mother’s Weight (kg):

Visina majke (cm) / Mother’s Height (cm):

Broj dece majke / Mother’s Number of Children:

Godina rođenja oca / Father’s Year of Birth:

Da li je otac živ? / Is your father alive?

Da / Yes

Ne / No

Godina smrti oca / Father’s Year of Death

Uzrok smrti oca / Father’s Cause of Death:

Boja očiju oca / Father’s Eye Color:

Plava / Blue

Zelena / Green

Smeđa / Brown

Drugo / Other:

Boja kose oca / Father’s Hair Color:

Plava / Blonde

Smeđa / Brown

Crna / Black

Drugo / Other:

Težina oca (kg) / Father’s Weight (kg):

Visina oca (cm) / Father’s Height (cm):

Broj dece oca / Father’s Number of Children:

Godina rođenja bake (majčina strana) / Maternal Grandmother’s Year of Birth:

Da li je baka (majčina strana) živa? / Is your maternal grandmother alive?

Da / Yes

Ne / No

Godina smrti bake (majčina strana) / Maternal Grandmother’s Year of Death:

Uzrok smrti bake (majčina strana) / Maternal Grandmother’s Cause of Death:

Boja očiju bake (majčina strana) / Maternal Grandmother’s Eye Color:

Plava / Blue

Zelena / Green

Smeđa / Brown

Drugo / Other:

Boja kose bake (majčina strana) / Maternal Grandmother’s Hair Color:

Plava / Blonde

Smeđa / Brown

Crna / Black

Drugo / Other:

Težina bake (kg) / Maternal Grandmother’s Weight (kg):

Visina bake (cm) / Maternal Grandmother’s Height (cm):

Godina rođenja dede (majčina strana) / Maternal Grandfather’s Year of Birth:

Da li je deda (majčina strana) živ? / Is your maternal grandfather alive?

Da / Yes

Ne / No

Godina smrti dede (majčina strana) / Maternal Grandfather’s Year of Death:

Uzrok smrti dede (majčina strana) / Maternal Grandfather’s Cause of Death:

Boja očiju dede (majčina strana) / Maternal Grandfather’s Eye Color:

Plava / Blue

Zelena / Green

Smeđa / Brown

Drugo / Other:

Boja kose dede (majčina strana) / Maternal Grandfather’s Hair Color:

Plava / Blonde

Smeđa / Brown

Crna / Black

Drugo / Other:

Težina dede (kg) / Maternal Grandfather’s Weight (kg):

Visina dede (cm) / Maternal Grandfather’s Height (cm):

Godina rođenja bake (očinska strana) / Paternal Grandmother’s Year of Birth:

Da li je baka (očinska strana) živa? / Is your paternal grandmother alive?

Da / Yes

Ne / No

Godina smrti bake (očinska strana) / Paternal Grandmother’s Year of Death:

Uzrok smrti bake (očinska strana) / Paternal Grandmother’s Cause of Death:

Boja očiju bake (očinska strana) / Paternal Grandmother’s Eye Color:

Plava / Blue

Zelena / Green

Smeđa / Brown

Drugo / Other:

Boja kose bake (očinska strana) / Paternal Grandmother’s Hair Color:

Plava / Blonde

Smeđa / Brown

Crna / BlackCrna / Black

Drugo / Other:

Težina bake (kg) / Paternal Grandmother’s Weight (kg):

Visina bake (cm) / Paternal Grandmother’s Height (cm):

Godina rođenja dede (očinska strana) / Paternal Grandfather’s Year of Birth:

Da li je deda (očinska strana) živ? / Is your paternal grandfather alive?

Da / Yes

Ne / No

Godina smrti dede (očinska strana) / Paternal Grandfather’s Year of Death:

Uzrok smrti dede (očinska strana) / Paternal Grandfather’s Cause of Death:

Boja očiju dede (očinska strana) / Paternal Grandfather’s Eye Color:

Plava / Blue

Zelena / Green

Smeđa / Brown

Drugo / Other:

Boja kose dede (očinska strana) / Paternal Grandfather’s Hair Color:

Plava / Blonde

Smeđa / Brown

Crna / Black

Drugo / Other:

Težina dede (kg) / Paternal Grandfather’s Weight (kg):

Visina dede (cm) / Paternal Grandfather’s Height (cm):

Da li nosite naočare ili kontaktna sočiva? / Do you wear glasses or contact lenses?

Da / Yes

Ne / No

Da li imate tetovaže? / Do you have tattoos?

Da / Yes

Ne / No

Da li imate pirsinge? / Do you have piercings?

Da / Yes

Ne / No

Kakav je vaš stav prema pušenju? / What is your attitude towards smoking?

Ne pušim / I do not smoke

Pušim povremeno / I smoke occasionally

Pušim redovno / I smoke regularly

Bivši pušač / Former smoker

Kakav je vaš stav prema upotrebi droga? / What is your attitude towards drug use?

Nikada nisam koristila / I have never used

Probala sam jednom ili dva puta / Tried once or twice

Povremeno koristim / I use occasionally

Redovno koristim / I use regularly

Koliko godina ste imali kada ste dobili prvu menstruaciju? / How old were you when you had your first period?

Da li su vam menstruacije redovne? / Are your periods regular?

Da, redovne su / Yes, they are regular

Ne, neredovne su / No, they are irregular

Da li u vašoj porodici postoje slučajevi višeplodnih trudnoća (blizanci, trojke, itd.)? / Are there cases of multiple pregnancies (twins, triplets, etc.) in your family?

Da / Yes

Ne / No

Koju vrstu kontracepcije trenutno koristite? / What type of contraception do you currently use?

Ne koristim kontracepciju / I do not use contraception

Pilule za kontracepciju / Birth control pills

Spiralu (IUD) / IUD

Prezervative / Condoms

Hormonsku injekciju / Hormonal injection

Drugo: / Other:

Koliko ste imali seksualnih partnera u poslednjih 12 meseci? / How many sexual partners have you had in the past 12 months?

Da li ste imali operacije? / Have you had any surgeries?

Ne, nikada nisam imala operacije / No, I have never had any surgeries

Da, koje? / Yes, which ones?

Da li imate alergije? / Do you have allergies?

Da / Yes

Ne / No

Ako imate, navedite na šta ste alergični / If yes, please specify:

Da li ste vi ili neko u vašoj porodici imali moždani udar? / Have you or anyone in your family had a stroke?

Da / Yes

Ne / No

Da li ste vi ili neko u vašoj porodici imali srčani udar? / Have you or anyone in your family had a heart attack?

Da / Yes

Ne / No

Da li vi ili neko u vašoj porodici imate bolest srca? / Do you or anyone in your family have heart disease?

Da / Yes

Ne / No

Da li vi ili neko u vašoj porodici imate srčane šumove? / Do you or anyone in your family have heart murmurs?

Da / Yes

Ne / No

Da li vi ili neko u vašoj porodici ima aterosklerozu (začepljenje arterija)? / Do you or anyone in your family have atherosclerosis (clogged arteries)?

Da / Yes

Ne / No

Da li vi ili neko u vašoj porodici ima visok krvni pritisak? / Do you or anyone in your family have high blood pressure?

Da / Yes

Ne / No

Da li vi ili neko u vašoj porodici ima visok nivo holesterola? / Do you or anyone in your family have high cholesterol?

Da / Yes

Ne / No

Da li vi ili neko u vašoj porodici ima anemiju (slabokrvnost)? / Do you or anyone in your family have anemia?

Da / Yes

Ne / No

Da li vi ili neko u vašoj porodici ima hemofiliju ili neku drugu bolest krvi? / Do you or anyone in your family have hemophilia or another blood disorder?

Da / Yes

Ne / No

Da li vi ili neko u vašoj porodici ima leukemiju? / Do you or anyone in your family have leukemia?

Da / Yes

Ne / No

Da li vi ili neko u vašoj porodici ima talasemiju? / Do you or anyone in your family have thalassemia?

Da / Yes

Ne / No

Da li vi ili neko u vašoj porodici imate astmu? / Do you or anyone in your family have asthma?

Da / Yes

Ne / No

Da li vi ili neko u vašoj porodici ima emfizem (oštećenje pluća)? / Do you or anyone in your family have emphysema (lung damage)?

Da / Yes

Ne / No

Da li vi ili neko u vašoj porodici ima tuberkulozu? / Do you or anyone in your family have tuberculosis?

Da / Yes

Ne / No

Da li vi ili neko u vašoj porodici ima rak pluća? / Do you or anyone in your family have lung cancer?

Da / Yes

Ne / No

Da li vi ili neko u vašoj porodici često ima upalu pluća? / Do you or anyone in your family frequently have pneumonia?

Da / Yes

Ne / No

Da li vi ili neko u vašoj porodici ima neku drugu bolest pluća? / Do you or anyone in your family have any other lung disease?

Da / Yes

Ne / No

Da li vi ili neko u vašoj porodici ima gastrični ili duodenalni čir (čir na želucu ili dvanaestopalačnom crevu)? / Do you or anyone in your family have a gastric or duodenal ulcer (stomach or duodenal ulcer)?

Da / Yes

Ne / No

Da li vi ili neko u vašoj porodici ima žučne kamence? / Do you or anyone in your family have gallstones?

Da / Yes

Ne / No

Da li vi ili neko u vašoj porodici ima hepatitis A? / Do you or anyone in your family have hepatitis A?

Da / Yes

Ne / No

Da li vi ili neko u vašoj porodici ima hepatitis B? / Do you or anyone in your family have hepatitis B?

Da / Yes

Ne / No

Da li vi ili neko u vašoj porodici ima hepatitis C? / Do you or anyone in your family have hepatitis C?

Da / Yes

Ne / No

Da li vi ili neko u vašoj porodici ima rak debelog creva? / Do you or anyone in your family have colon cancer?

Da / Yes

Ne / No

Da li vi ili neko u vašoj porodici ima ulcerozni kolitis? / Do you or anyone in your family have ulcerative colitis?

Da / Yes

Ne / No

Da li vi ili neko u vašoj porodici ima Kronovu bolest? / Do you or anyone in your family have Crohn’s disease?

Da / Yes

Ne / No

Da li vi ili neko u vašoj porodici ima rak creva? / Do you or anyone in your family have intestinal cancer?

Da / Yes

Ne / No

Da li vi ili neko u vašoj porodici ima cirozu jetre? / Do you or anyone in your family have liver cirrhosis?

Da / Yes

Ne / No

Da li vi ili neko u vašoj porodici ima probleme sa rektumom (hemoroidi, fistule, druge bolesti)? / Do you or anyone in your family have rectal disorders (hemorrhoids, fistulas, or other conditions)?

Da / Yes

Ne / No

Da li vi ili neko u vašoj porodici ima druge probleme sa probavnim sistemom? / Do you or anyone in your family have other digestive system issues?

Da / Yes

Ne / No

Da li vi ili neko u vašoj porodici imate dijabetes melitus (šećernu bolest)? / Do you or anyone in your family have diabetes mellitus?

Da / Yes

Ne / No

Da li vi ili neko u vašoj porodici ima hipoglikemiju (nizak nivo šećera u krvi)? / Do you or anyone in your family have hypoglycemia (low blood sugar)?

Da / Yes

Ne / No

Da li vi ili neko u vašoj porodici ima bolest štitne žlezde? / Do you or anyone in your family have a thyroid disease?

Da / Yes

Ne / No

Da li vi ili neko u vašoj porodici ima gušavost (uvećanu štitnu žlezdu)? / Do you or anyone in your family have a goiter (enlarged thyroid gland)?

Da / Yes

Ne / No

Da li vi ili neko u vašoj porodici ima poremećaj nadbubrežne žlezde? / Do you or anyone in your family have an adrenal gland disorder?

Da / Yes

Ne / No

Da li vi ili neko u vašoj porodici ima fenilketonuriju (genetski poremećaj metabolizma)? / Do you or anyone in your family have phenylketonuria (a genetic metabolic disorder)?

Da / Yes

Ne / No

Da li vi ili neko u vašoj porodici ima bolest bubrega? / Do you or anyone in your family have kidney disease?

Da / Yes

Ne / No

Da li vi ili neko u vašoj porodici ima urolitijazu (bubrežne kamence)? / Do you or anyone in your family have urolithiasis (kidney stones)?

Da / Yes

Ne / No

Da li vi ili neko u vašoj porodici ima neku drugu bolest urinarnog sistema? / Do you or anyone in your family have any other urinary system disease?

Da / Yes

Ne / No

Da li vi ili neko u vašoj porodici ima rak prostate? / Do you or anyone in your family have prostate cancer?

Da / Yes

Ne / No

Da li vi ili neko u vašoj porodici ima miome materice? / Do you or anyone in your family have uterine fibroids?

Da / Yes

Ne / No

Da li vi ili neko u vašoj porodici ima endometriozu? / Do you or anyone in your family have endometriosis?

Da / Yes

Ne / No

Da li vi ili neko u vašoj porodici ima rak grlića materice? / Do you or anyone in your family have cervical cancer?

Da / Yes

Ne / No

Da li vi ili neko u vašoj porodici ima ciste na jajnicima? / Do you or anyone in your family have ovarian cysts?

Da / Yes

Ne / No

Da li vi ili neko u vašoj porodici ima rak materice? / Do you or anyone in your family have uterine cancer?

Da / Yes

Ne / No

Da li vi ili neko u vašoj porodici ima rak testisa? / Do you or anyone in your family have testicular cancer?

Da / Yes

Ne / No

Da li ste vi ili neko u vašoj porodici imali pobačaj ili mrtvorođeno dete? / Have you or anyone in your family had a miscarriage or stillbirth?

Da / Yes

Ne / No

Da li ste vi ili neko u vašoj porodici imali rani neonatalni smrtni slučaj? / Have you or anyone in your family had an early neonatal death?

Da / Yes

Ne / No

Da li ste vi ili neko u vašoj porodici imali prevremenu menopauzu (pre 40. godine)? / Have you or anyone in your family experienced early menopause (before age 40)?

Da / Yes

Ne / No

Da li vi ili neko u vašoj porodici ima migrene? / Do you or anyone in your family have migraines?

Da / Yes

Ne / No

Da li vi ili neko u vašoj porodici ima mentalnu retardaciju? / Do you or anyone in your family have intellectual disability?

Da / Yes

Ne / No

Da li vi ili neko u vašoj porodici ima Daunov sindrom? / Do you or anyone in your family have Down syndrome?

Da / Yes

Ne / No

Da li vi ili neko u vašoj porodici ima Tarnerov sindrom? / Do you or anyone in your family have Turner syndrome?

Da / Yes

Ne / No

Da li vi ili neko u vašoj porodici ima Krhki X sindrom? / Do you or anyone in your family have Fragile X syndrome?

Da / Yes

Ne / No

Da li vi ili neko u vašoj porodici ima multiplu sklerozu? / Do you or anyone in your family have multiple sclerosis?

Da / Yes

Ne / No

Da li vi ili neko u vašoj porodici ima cerebralnu paralizu? / Do you or anyone in your family have cerebral palsy?

Da / Yes

Ne / No

Da li vi ili neko u vašoj porodici ima epilepsiju ili je imao napade? / Do you or anyone in your family have epilepsy or seizures?

Da / Yes

Ne / No

Da li vi ili neko u vašoj porodici ima hidrocefalus? / Do you or anyone in your family have hydrocephalus?

Da / Yes

Ne / No

Da li vi ili neko u vašoj porodici ima poremećaje kičmene moždine? / Do you or anyone in your family have spinal cord disorders?

Da / Yes

Ne / No

Da li vi ili neko u vašoj porodici ima Hantingtonovu bolest? / Do you or anyone in your family have Huntington’s disease?

Da / Yes

Ne / No

Da li vi ili neko u vašoj porodici ima Goseovu bolest? / Do you or anyone in your family have Gaucher disease?

Da / Yes

Ne / No

Da li vi ili neko u vašoj porodici ima Kanavanovu bolest? / Do you or anyone in your family have Canavan disease?

Da / Yes

Ne / No

Da li vi ili neko u vašoj porodici ima Taj-Saksovu bolest? / Do you or anyone in your family have Tay-Sachs disease?

Da / Yes

Ne / No

Da li vi ili neko u vašoj porodici ima Vilsonovu bolest? / Do you or anyone in your family have Wilson’s disease?

Da / Yes

Ne / No

Da li vi ili neko u vašoj porodici ima Parkinsonovu bolest? / Do you or anyone in your family have Parkinson’s disease?

Da / Yes

Ne / No

Da li vi ili neko u vašoj porodici ima Alchajmerovu bolest? / Do you or anyone in your family have Alzheimer’s disease?

Da / Yes

Ne / No

Da li vi ili neko u vašoj porodici ima demenciju? / Do you or anyone in your family have dementia?

Da / Yes

Ne / No

Da li vi ili neko u vašoj porodici ima neku drugu bolest nervnog sistema? / Do you or anyone in your family have any other nervous system disease?

Da / Yes

Ne / No

Da li vi ili neko u vašoj porodici ima neku drugu bolest nervnog sistema? / Do you or anyone in your family have any other nervous system disease?

Da / Yes

Ne / No

Da li vi ili neko u vašoj porodici ima šizofreniju? / Do you or anyone in your family have schizophrenia?

Da / Yes

Ne / No

Da li vi ili neko u vašoj porodici ima bipolarni poremećaj? / Do you or anyone in your family have bipolar disorder?

Da / Yes

Ne / No

Da li vi ili neko u vašoj porodici ima depresiju? / Do you or anyone in your family have depression?

Da / Yes

Ne / No

Da li je bilo slučajeva samoubistva u vašoj porodici? / Has there been a case of suicide in your family?

Da / Yes

Ne / No

Da li vi ili neko u vašoj porodici ima neki drugi mentalni poremećaj? / Do you or anyone in your family have any other mental disorder?

Da / Yes

Ne / No

Da li vi ili neko u vašoj porodici ima mišićnu distrofiju? / Do you or anyone in your family have muscular dystrophy?

Da / Yes

Ne / No

Da li vi ili neko u vašoj porodici ima neku hroničnu bolest mišića? / Do you or anyone in your family have a chronic muscle disease?

Da / Yes

Ne / No

Da li vi ili neko u vašoj porodici ima sistemski lupus? / Do you or anyone in your family have systemic lupus?

Da / Yes

Ne / No

Da li vi ili neko u vašoj porodici ima spinalne deformacije (iskrivljenje kičme, skolioza, kifoza)? / Do you or anyone in your family have spinal deformities (scoliosis, kyphosis)?

Da / Yes

Ne / No

Da li vi ili neko u vašoj porodici ima osteoporozu? / Do you or anyone in your family have osteoporosis?

Da / Yes

Ne / No

Da li vi ili neko u vašoj porodici ima patuljast rast (dwarfizam)? / Do you or anyone in your family have dwarfism?

Da / Yes

Ne / No

Da li vi ili neko u vašoj porodici ima reumatoidni artritis? / Do you or anyone in your family have rheumatoid arthritis?

Da / Yes

Ne / No

Da li vi ili neko u vašoj porodici ima osteoartritis? / Do you or anyone in your family have osteoarthritis?

Da / Yes

Ne / No

Da li vi ili neko u vašoj porodici ima giht? / Do you or anyone in your family have gout?

Da / Yes

Ne / No

Da li vi ili neko u vašoj porodici ima rascep nepca ili usne? / Do you or anyone in your family have a cleft palate or cleft lip?

Da / Yes

Ne / No

Da li ste vi ili neko u vašoj porodici izgubili sluh pre 60. godine? / Have you or anyone in your family experienced hearing loss before the age of 60?

Da / Yes

Ne / No

Da li vi ili neko u vašoj porodici ima deformaciju uha? / Do you or anyone in your family have an ear deformity?

Da / Yes

Ne / No

Da li ste vi ili neko u vašoj porodici imali kataraktu pre 50. godine? / Have you or anyone in your family had cataracts before the age of 50?

Da / Yes

Ne / No

Da li ste vi ili neko u vašoj porodici slepi ili imaju ozbiljan gubitak vida? / Are you or anyone in your family blind or have severe vision loss?

Da / Yes

Ne / No

Da li vi ili neko u vašoj porodici ima daltonizam (poremećaj raspoznavanja boja)? / Do you or anyone in your family have color blindness?

Da / Yes

Ne / No

Da li vi ili neko u vašoj porodici ima devijaciju nosne pregrade? / Do you or anyone in your family have a deviated nasal septum?

Da / Yes

Ne / No

Da li vi ili neko u vašoj porodici ima glaukom? / Do you or anyone in your family have glaucoma?

Da / Yes

Ne / No

Da li vi ili neko u vašoj porodici ima retinitis pigmentosa (nasledno degenerativno oboljenje mrežnjače)? / Do you or anyone in your family have retinitis pigmentosa (a hereditary degenerative retinal disease)?

Da / Yes

Ne / No

Da li vi ili neko u vašoj porodici ima druge probleme sa vidom, sluhom ili mirisom? / Do you or anyone in your family have any other vision, hearing, or smell disorders?

Da / Yes

Ne / No

Da li vi ili neko u vašoj porodici ima problema sa aknama? / Do you or anyone in your family have acne?

Da / Yes

Ne / No

Da li vi ili neko u vašoj porodici ima ekcem? / Do you or anyone in your family have eczema?

Da / Yes

Ne / No

Da li vi ili neko u vašoj porodici ima rak kože? / Do you or anyone in your family have skin cancer?

Da / Yes

Ne / No

Da li vi ili neko u vašoj porodici ima poremećaje pigmentacije kože (vitiligo, melazma, albinizam)? / Do you or anyone in your family have skin pigmentation disorders (vitiligo, melasma, albinism)?

Da / Yes

Ne / No

Da li vi ili neko u vašoj porodici ima neurofibromatozu (genetski poremećaj koji uzrokuje tumore na nervima)? / Do you or anyone in your family have neurofibromatosis (a genetic disorder that causes tumors on nerves)?

Da / Yes

Ne / No

Da li vi ili neko u vašoj porodici ima druge lezije ili hronične probleme sa kožom? / Do you or anyone in your family have other skin lesions or chronic skin conditions?

Da / Yes

Ne / No

Da li vi ili neko u vašoj porodici ima problem sa alkoholizmom? / Do you or anyone in your family have alcoholism?

Da / Yes

Ne / No

Da li vi ili neko u vašoj porodici ima istoriju zloupotrebe supstanci (droga, lekova, itd.)? / Do you or anyone in your family have a history of substance abuse (drugs, medications, etc.)?

Da / Yes

Ne / No

Da li vi ili neko u vašoj porodici ima rak dojke? / Do you or anyone in your family have breast cancer?

Da / Yes

Ne / No

Da li je neko u vašoj porodici preminuo pre 50. godine iz zdravstvenih razloga? / Has anyone in your family died before the age of 50 due to health reasons?

Da / Yes

Ne / No

Da li vi ili neko u vašoj porodici ima neki drugi oblik raka? / Do you or anyone in your family have any other type of cancer?

Da / Yes

Ne / No

Ako da, koji? / If yes, specify:

Da li vi ili neko u vašoj porodici ima kongenitalne probleme sa kukovima (urođeni problemi)? / Do you or anyone in your family have congenital hip problems (birth-related issues)?

Da / Yes

Ne / No

Da li vi ili neko u vašoj porodici ima klupko stopalo (urođeno krivo stopalo)? / Do you or anyone in your family have clubfoot (congenital foot deformity)?

Da / Yes

Ne / No

Da li vi ili neko u vašoj porodici ima neku drugu bolest koja nije pomenuta u upitniku? / Do you or anyone in your family have any other illness not mentioned in this questionnaire?

Ako da, navedite: / If yes, specify:

Ne / No

Ako da, navedite: / If yes, specify:

Da li vi ili neko u vašoj porodici ima autoimunu bolest (npr. lupus, Hashimoto, reumatoidni artritis)? / Do you or anyone in your family have an autoimmune disease (e.g., lupus, Hashimoto’s, rheumatoid arthritis)?

Ako da, navedite: / If yes, specify:

Ne / No

Ako da, navedite: / If yes, specify:

Ostavite ličnu poruku budućim roditeljima deteta rođenog zahvaljujući vašoj donaciji. Ovo može biti nešto o vašoj motivaciji za donaciju, želje za njihovu porodicu ili bilo koja pozitivna misao koju želite da podelite. (Leave a personal message to the future parents of the child born thanks to your donation. This could be something about your motivation for donation, wishes for their family, or any positive thoughts you’d like to share.)

Ako želite, možete ostaviti poruku detetu koje će biti rođeno zahvaljujući vašoj donaciji. Možete mu poželeti sreću, zdravlje ili podeliti nešto lično i inspirativno. (If you wish, you can leave a message for the child who will be born thanks to your donation. You may wish them happiness, health, or share something personal and inspiring.)

Slažem se da ova veb stranica čuva moje dostavljene informacije kako bi mogli da odgovore na moj upit.

Pročitala sam i slažem se sa Uslovima korišćenja i Politikom privatnosti.