Surrogacy History
Yes, I have surrogate experience
First time surrogate
Name
*
First Name
Last Name
Email
*
Phone
*
(###)
###
####
State / Country
*
Date of Birth
MM
DD
YYYY
Blood Type
Rh Factor
Height
Current BMI
Natural Hair Color
Your Ethnicity/ Origin
Marital status
*
Legally Married
Separated - still Legally Married
In a Relationship
Single
Education Level
Are you a citizen or permanent resident of the United States?
*
Are you currently employed?
*
If working, please provide your job description and title
How long have you worked for your current employer?
How many hours per week do you work and what is your hourly rate?
Please provide information about your spouse/ partner's job:
Do you have a valid driver's license?
*
Are you in a stable living situation?
*
What language(s) do you speak with your family?
Hobbies
Have any pet(s)?
Dog
Cat
Horse
Fish
Reptiles
Other small animal
Within the past 12 months, have you done any traveling to another country?
Your favorite foods
Do your child(ren) live with you?
How many adults (over 18 years of age) are living in the home with you?
How does your spouse or significant other feel about you becoming a gestational surrogate?
Does your current spouse or partner smoke?
Have you or anyone in your current household ever been arrested and/or convicted of a crime/felony?
Are you currently sexually active?
Which contraceptive method are you currently using?
If you become pregnant via surrogacy, can you completely refrain from using alcohol, tobacco, and all other medications not prescrived by your physician for the entire duration of your pregnancy, and abstain from sexual intercourse when directed by a physician?
Is your health condition generally healthy?
Are you currently taking any medication(s)?
Are you under a family doctor's care?
Do you have any emotional or depression problem?
Do you were corrective lenses?
Do you have normal hearing?
Do you currently have ANY medical problems or conditions we should be aware of?
Do you have a history of drug abuse?
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Do you have a history of alcohol abuse?
*
Have you ever taken any growth hormones?
Have you ever taken any non-prescribed steoids?
Do you use any prescription drugs, even if not prescribed by a licensed physician?
Have you had any of the following conditions?
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Allergy problem as: Medication Allergy, Food Allergy, Sinusitis Rhinitis
Endocrine problem as: Diabetes Mellitus, Hypoglycemia, Hyperthyroidism Hyperparathyroidism
Blood & Circulation problem as: Anemia, Hemophilia Leukemia, Lymphoma
Eye/Ear/Nose/Throat problem as Cataracts, Malformation, Macular Degeneration, Joint Dysfunction
Cardiovascular problem as: Angina, Heart Failure, Hypertension, Stroke
Digestion problem as: Cirrhosis, Hepatitis, Viral, Pancreatitis, Gallbladder Disease
Skin problem as: Acne, Erythema, Hirsutism, Psoriasis
Musculoskeletal problem as: Gout, Lupus, Arthritis, Osteoporosis
Psychology problem as: Alcoholism, Dementia, Depression, PTSD
Reproductive problem as: PCOS, Ovarian Cysts, Vaginitis, Endometriosis
Any known cancer condition as: Breast Cancer, Cervical Cancer, Colorectal Cancer, Skin Cancer
Have you ever had any type of surgery?
Have you had any plastic surgery?
Do you use any recreational drugs?
Do you have any allergies?
Have you ever been diagnosed with or taken medication for psychological problems, including depression or anxiety?
Have you ever attempted suicide or had suicidal thoughts?
How old were you at your first menstrual cycle?
When was your last menstrual period?
MM
DD
YYYY
How long is your menstrual period?
How many days between periods?
Do you have regular cycle?
Your method of birth control?
Use Birth Control Pill
Use Contraceptive Ring
No, I have never used birth control pill or ring
When was your last PAP SMEAR?
MM
DD
YYYY
Was the result normal?
Have you ever been treated for a STI?
Have you ever injected non therapeutic drugs?
Number of pregnancies (please include miscarriages and abortions)
Pregnancy #1
*
Pregnancy #2
*
Pregnancy #3
*
Pregnancy #4
*
Pregnancy #5
*
Have you had at least 1 delivery, but no more than 5 and no more than 3 prior c-section deliveries?
*
Have you had any ectopic pregnancy?
Please list any previous pregnancy complications (if any):
If you have given birth as a surrogate, please provide the following information, and how many attemps until each successful embryo transfer?
Date| Weight| Single or Double embryo transfer? | Delivery Method
Please mark all that applies to your match preferences:
What does being a surrogate mean to you personally?
Do you have any concerns about becoming a surrogate?
We prefer to do a total of 3 transfer attempts for each match - if unsucessful, are you fine with this?
If your partner and/or your close family supportive of your decision to become a surrogate?
Please describe your support system: for instance, w ho would help you if you were on doctor ordered bed rest for a period of time?
Do you have a preferred OB provider and hospital you would like to use for surrogacy journey? Please provide the names and locations of these providers:
What do you think of communication of the IPs using email, phone calls or text? Would you be able to check in regularly?
What kind of relationship would you prefer with the intended parents after the birth of the child(ren)?
How do you feel about the possibility of carrying more than one baby as a surrogate? Would you be willing to carry twins?
If medically recommended (due to quality of life or possible death after birth), are you okay with terminating the pregnancy up to 24 weeks gestation?
Are there any specific conditions if which you would not terminate a pregnancy? If yes (conditions not to terminate), please explain:
What is your message to the potential intended parent(s)?
