Full Name:
City, State:
Address:
Email:
Contact number:
Emergency contact:
Emergency contact number:
What is the best way to contact you?
Are you citizenship or green card holder?
What is your base fee for this surrogacy?
Birth Date
Ethnicity
Height
Current weight
Have you ever been a surrogate?
How long have you been considering becoming a gestational surrogate?
How did you become interested in becoming a gestational surrogate?
What does being a surrogate mother mean to you?
How did you hear about us?
Employer:
Occupation and duties:
Is your schedule flexible?
Who is the primary source of income in your household?
How many hours a week do you work on average?
What is your educational background?
Have you ever been convicted of a crime? If yes, what crime?
What is your relationship status?
Are you currently in a monogamous relationship?
What is your partner's first name:
Date of birth:
Partner's ethnicity:
What is your partner's educational background:
Describe the type of work that your partner does:
How long have you been in a relationship with your partner?
How does your partner feel about you becoming a surrogate?
Is your partner in good health?
Does y our partner or anyone you live with smoke?
Has your partner ever been convicted of a crime?
List those that currently reside in your household:
What relationship do you want with the intended parents during the pregnancy?
What relationship would you like to have with the intended parents after delivery and beyond?
Would you be willing to work with a same sexed couple or single parent?
Many intended parents do not live near their surrogate and could live in another country. How do you feel about having intended parents that do not live near you?
Would you be willing to pump breast milk if the intended parents ask??
Please list the first names of family, friends, coworkers and children who will support you during your surrogacy process:
If you were placed on doctor ordered best rest for a period of time, who will be your support system for you and your children?
Have you ever given a child up for adoption?
1- How many times have you been pregnant:
How many live births:
Pregnancy #1
Outcome:
Vaginal or C- section:
Weeks at conclusion of pregnancy:
Complications during pregnancy: explanation fields.
Did you have any trouble getting pregnant?
Do you have a family history of fertility problems (describe):
Child's First Name:
Birth Date:
Birth Weight:
Length of child (in inches):
Health of Child:
Pregnancy #2
Outcome:
Vaginal or C- section:
Weeks at conclusion of pregnancy:
Complications during pregnancy: explanation fields.
Did you have any trouble getting pregnant?
Do you have a family history of fertility problems (describe):
Child's First Name:
Birth Date:
Birth Weight:
Length of child (in inches):
Health of Child:
Pregnancy #3
Outcome:
Vaginal or C- section:
Weeks at conclusion of pregnancy:
Complications during pregnancy: explanation fields.
Did you have any trouble getting pregnant?
Do you have a family history of fertility problems (describe):
Child's First Name:
Birth Date:
Birth Weight:
Length of child (in inches):
Health of Child:
Pregnancy #4
Outcome:
Vaginal or C- section:
Weeks at conclusion of pregnancy:
Complications during pregnancy: explanation fields.
Did you have any trouble getting pregnant?
Do you have a family history of fertility problems (describe):
Child's First Name:
Birth Date:
Birth Weight:
Length of child (in inches):
Health of Child:
Pregnancy #5
Outcome:
Vaginal or C- section:
Weeks at conclusion of pregnancy:
Complications during pregnancy: explanation fields.
Did you have any trouble getting pregnant?
Do you have a family history of fertility problems (describe):
Child's First Name:
Birth Date:
Birth Weight:
Length of child (in inches):
Health of Child:
Pregnancy #6
Outcome:
Vaginal or C- section:
Weeks at conclusion of pregnancy:
Complications during pregnancy: explanation fields.
Did you have any trouble getting pregnant?
Do you have a family history of fertility problems (describe):
Child's First Name:
Birth Date:
Birth Weight:
Length of child (in inches):
Health of Child:
Pregnancy #7
Outcome:
Vaginal or C-section:
Weeks at conclusion of pregnancy:
Complications during pregnancy:
Did you have any trouble getting pregnant?
Do you have a family history of fertility problems (describe):
Child's First Name:
Birth Date:
Birth Weight:
Length of child (in inches):
Health of Child:
Do you have any current or past health concerns (describe):
Prior Surgeries
List any medications (prescription and non-prescription), vitamins and nutritional supplements you are currently taking and dosage:
List all prescription medications and dosages you have taken in the last year and the reason for taking them:
How often do you go to the doctor?
Are you COVID vaccinated? If not, would you be willing to take it if required by the clinic or intended parents?
How many days does your period last:
Describe your current method of birth control:
Have you ever been hospitalized other than giving birth (describe):
When was your last pap smear?
What were your pap smear results:
When was your last screening for STDs?
Have you ever been in therapy or counseling? (describe reason):
Do you have any allergies (describe):
How often do you drink alcoholic beverages?
Describe your daily diet: 3 meals a day plus snacks.
How often do you cook at home?
How often do you eat out?
What are your favorite foods?
What is your favorite restaurant?
Do you currently exercise or work out? Please describe your current exercise method:
Do you work out or exercise while pregnant? If so, what is your preferred form of Prenatal exercise?
Describe your lifestyle and typical day-to-day activities:
What do you like doing most with your family?
What activities do you enjoy for fun and recreation:
What do you do to pamper yourself?
What do you do to relax?
What do you like to do in your spare time?
What is your favorite color?
Do you like flowers? If so, what type?
Describe the home you live in and your neighborhood:
Is there anything you would like to add about yourself for the Intended Parents?
Do you currently have medical (health) insurance?
If you have medical (health) insurance, what is the name of your insurance company?
If you have medical (health) insurance, what is your deductible or copay information?
Is your medical (health) insurance through your employer, husband's employer, or an individual policy?
Do you have life insurance?
Do you currently have car insurance?
If bed rest is prescribed during pregnancy, will you require childcare assistance?
Two embryo transfers are standard to give the parents the best chance at a single pregnancy. Are you willing to have two embryos transferred?
Are you willing to allow the doctor to decide the best number of embryos to transfer to achieve a single pregnancy (no more than three) Are you willing to carry twins?
Would you be willing to terminate pregnancy if medically advised?
If the fetus is diagnosed with a fatal or debilitating disease, would you be willingto terminate the pregnancy?
If the fetus were diagnosed with Down Syndrome (Trisomy 21), would you be willing to terminate the pregnancy?
If you were to become pregnant with more than triplets (3), would you be willing to reduce the number of embryos within the first trimester if requested by the Intended Parents?
Are you willing to pump breast milk for the baby?
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