General Information


First Name:

State born in:

Age:

Race:

Years Married:




Surrogate Physical Description


Height:

Weight:


Education


High School Grade Point Average:

Attended college?

Learning disabilities?

Additional Education information:




Family Health History


Relation: Mother
Year of Birth:
Race:
Ethnic Ancestry:
Sex and Age of Children:
Occupation:
Education:
Type of personality:



Relation: Father
Year of Birth:
Race:
Ethnic Ancestry:
Sex and Age of Children:
Occupation:
Education:
Type of personality:



Relation: Grandmother-Paternal
Year of Birth:
Race:
Ethnic Ancestry:
Sex and Age of Children:
Occupation:
Education:
Type of personality:



Relation: Grandfather-Paternal
Year of Birth:
Race:
Ethnic Ancestry:
Sex and Age of Children:
Occupation:
Education:
Type of personality:



Relation: Grandmother-Maternal
Year of Birth:
Race:
Ethnic Ancestry:
Sex and Age of Children:
Occupation:
Education:
Type of personality:



Relation: Grandfather-Maternal
Year of Birth:
Race:
Ethnic Ancestry:
Sex and Age of Children:
Occupation:
Education:
Type of personality:




How many siblings do you have?


Where are you in this birth order?




Personal Profile


Do you or anyone in your household smoke?


Have you ever received treatment for drug and/or alcohol abuse? If yes, please explain:


Do you drink alcohol? If yes, when and how often:


Do you take any non-prescription drugs? If yes, please indicate which ones and the reason:


Are you willing to take health related tests at the expense of the prospective parent(s)?


Have you had any sexually transmitted diseases? (herpes, hepatitis, HIV, etc.) If yes, please specify:



Please list any significant illnesses you have had:


What was the date of your last check-up with your doctor and its results?


Please list any prescription drugs you are currently taking and any medical conditions for which you are currently being seen or treated:




Have you ever been under the care of a psychiatrist? (Hospitalization, medication, on-going therapy?) If yes, please explain:


Have you or anyone in your household ever been arrested and/or convicted of a crime/felony? If yes, please explain:


Please describe your future goals (personal and career):



Briefly explain your personal reasons for wanting to be a surrogate:







Do you want to have any more children?



What qualities do you consider to be most important in choosing to work with prospective parents?



As a surrogate, would you have any concerns with the prospective parents participating in the birthing process?




As a surrogate, what reassurance can you give that you will not change your mind about relinquishing the child?




How do you feel being a gestational surrogate with affect your life? How might it prove difficult?





How much contact were you thinking you would like with the parents during pregnancy, delivery and after the child is born?




What would your response be if the child wanted to meet you?




Would you like to request any contact with the child after the child is born? If yes, do you wish to receive: (pictures, letters, visits, phone calls, ...); how often?





During a surrogacy process, who can you expect to receive emotional support from:





How do your parents and friends feel about your becoming a surrogate, if you've told them?






Is your husband/partner aware of his responsibilities in the medical process and how willing is he to cooperate (such as abstinence, testing )?





Have you ever been a surrogate or an ovum donor? If yes, when?





What are your biggest worries and concerns about becoming a gestational surrogate?





If your doctor recommended an amniocentesis, would you consent?





In the event of a major birth defect, would you consider an abortion?




How many transfer attempts would you feel comfortable with in order to become pregnant?





If your obstetrician recommended bed rest, would this be a problem for you? What do you consider as adequate compensation for your surrogacy?, please be specific.




Is there anything you consider important that was not covered in this form?



Reproductive Health History


Please list any reproductive illnesses (miscarriages, abortions, premature delivery or stillbirths ) or diseases that you have experienced: (Please indicate the date(s), complications, outcome, extenuating circumstances, etc.)





How many times have you been pregnant?


Please list the approximate dates of your pregnancies:


Please list the age, sex and general health condition of each of your children:





Were all of your children born healthy? If no, please explain:




Were any of them born at an extremely high or low weight? If yes, please explain:


Do you have legal and physical custody of all the above children? If no, please explain:


If you have experienced any complications with any of your pregnancies, please explain the circumstances :


Which type of birth control are you currently using?


Did any of your pregnancies take longer than 6 months to conceive?


Did you need any medical assistance to conceive your children? If yes, please explain: