General information

This page will not be part of your profile that Prospective Parents will review.
Date
Surrogate's Name
Husband's Name
Mailing Address
City
State
Zip
Home Telephone
Home Fax
 
Surrogate Husband/Partner
E-Mail Address
Mobile Telephone
Social Security
Occupation
Date of Birth (mm/dd/yyyy)
Employer
Employer's Address
Employer's Telephone

Emergency Contact

Person to contact in case of an emergency, not your spouse or partner.
Name
Telephone
Address
City
State
Zip
Relationship To You
Family Annual Income

Characteristics & Social History

This page will be part of your profile that Prospective Parents will review.
First Name Only
Location (State Only)
Date of Birth
Marital Status
Age
Hair Color
Eye Color
Complexion
Height
Weight
Blood Type
Race
Religion

Ethnic Background
Example French, German

Educational Background
And Other Training Certificates
Number of Children
Sex and Age of Children
Type of Surrogacy Traditional
Gestational
Either
Do you smoke? No     Yes
If yes, frequency
Do you work in a smoking
environment?
No    Yes
If yes, Describe
Do you drink alcohol? No    Yes
If yes, frequency
Have you used, or currently
using any illegal drugs?
No    Yes
If yes, when, what and how much?
Have you ever been arrested for a criminal offense? No    Yes
If yes, please give dates and details
Do you have Health Insurance? No    Yes
If yes, please include a copy of your insurance card so we can check your benefits.
Name of Health Insurance Company
Effective Date
Deductible
Does it provide coverage for maternity? No    Yes    Unsure
Do you have a car? No    Yes
If no, do you have transportation to appointments?
Is your schedule flexible, as you will be attending many doctor appointments? No    Yes
Which of the following potential parents, would you be willing to work with? A couple that lives in another state
A couple that lives in another country
A couple that already has children
Heterosexual Couple looking for Gestational Surrogate
Heterosexual Couple looking for Traditional Surrogate
Heterosexual Single Father
Heterosexual Single Mother
Homosexual Male Couple
Homosexual Female Couple
Homosexual Single Mother
Other
Other, please describe
What characteristics are you looking for in potential intended parents?
Why are you interested in Surrogacy?
What contact do you want, before, during and after the pregnancy?
Do you have any objections to carrying multiples?    No     Yes
If yes, please explain
What is your view on selective reduction (reducing down), if you get pregnant with more than one baby?
Would you allow the Prospective Parents to make this decision for the health of their children?
No     Yes
If no, please explain:
If the parents wanted to, would you be willing to abort the pregnancy if the child had severe physical or mental abnormalities?
Will you be able to locate assistance to help with your children, if for any medical reason, you are told to be on bed rest?
No     Yes
What makes you think you could give up a child?
What is your philosophy of life?
What are your goals?
Have you achieved any of these goals yet?
Describe your self as a child:
Medical History: Surrogate & Family:
General Health:
Congenital Diseases
Medical Diseases:
Previous surgeries and hospitalizations and reasons for the:
Do you have a menstrual cycle every month? Yes    No
How many days are between the first day of your period and your next one?
Are you currently breast-feeding? Yes    No
If so, how often?
When are you planing to stop?
Type of birth control you are using
How long have you used this form of birth control?
If you are using Norplant, or Depo Provera shot, are you willing to discontinue them to
try and become pregnant as a surrogate in our program?   
Yes    No
What was the date of your last Pap Smear?
Results?
Have you ever been medicated or hospitalized for psychiatric reasons?
Are there any known genetic conditions or birth defects in your family?
Current Medications:
Allergies:
Food, drugs…

 

Please list names, age on onset of disease, age and cause of death of your parents, siblings,
Maternal grandparents, paternal grandparents, aunts, uncle or cousins that have had serious medical problem, have died or have any birth or congenital defect:

Family Member Alive Dead Age Description
Father
Mother
Brother(s)
Sister(s)
Maternal Grandfather
Maternal Grandmother
Paternal Grandfather
Paternal Grandmother
Aunt(s)
Uncle(s)
Cousin(s)

Marriage and pregnancy information:
Date of current marriage, city, county and state:
Dates of previous marriages:
Dates of divorces, city, county and state of divorce:
Number of
Pregnancies
Live Born Miscarriages Abortions Date of Birth
or Loss
Birth Weight & Length
Have you experienced any of the following pregnancy complications? Pre-term Labor
Gestational Diabetes
Placenta Previa
Home Monitoring
Emergency Cesarean
Other
Does your child(ren) live with you? Yes    No
Are any of your children adopted? Yes    No
Present Obstetrician:
Phone
Address
City
State
Zip
Present Pediatrician:
Phone
Address
City
State
Zip
Have you been a surrogate mother before?    Yes    No
If yes, please answer the following questions
How many times have you been a surrogate?
Were you Traditional or Gestational Surrogate?
Did you do Artificial Insemination or In-Vitro?
Did you work with an agency?    Yes    No
If yes, which one?
How was your experience with this agency?
Were you carrying:
Singleton    Twins    Triplets    Quads
How many tries did it take before you got pregnant?
Any canceled cycles?     Yes    No
If yes, please explain
Any complications while on medications?    Yes     No
If yes, please explain
Did you undergo selective reduction?    Yes    No
If yes, please explain why:
What was your previous Intended Parents Like:
Tell us about your surrogate experience:
How did you feel after the delivery? (Any depression, separation anxiety with the baby)
How can we, as well as the new Intended Parents make your next experience better:
List two references and their phone numbers that you have known for at least five years: