Name _______________________________________________________________________
Address _____________________________________________________________________
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Home telephone number _________________________________________________________
Work telephone number _________________________________________________________
E-mail address _________________________________________________________________
Age ________________
Education ____________________________________________________________________
Occupation ___________________________________________________________________
Employer ____________________________________________________________________
Marital Status _________________________________________________________________
If married, does your husband support your decision to become a surrogate? ________________
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Height ________________________
Weight ________________________
List all medications currently taken _________________________________________________
______________________________________________________________________________
______________________________________________________________________________
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List all surgeries and hospitalizations in last 10 years __________________________________
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List all known health problems ____________________________________________________
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Do you suffer from mental illness? _________________________________________________
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Do you have any sexually transmitted diseases? ______________________________________
______________________________________________________________________________
Have you ever been tested for AIDS and/or HIV? __________ Results ___________________
Do you consume alcohol? _____ Quantity __________________________________________
Do you smoke? _____ Quantity __________________________________________________
Do you now or have you ever used illegal drugs? _____________________________________
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List all known health problems of your parents and siblings
______________________________________________________________________________
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Do you have children? _____ List ages ____________________
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List all health concerns relating to your children
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Did you have normal pregnancies? _____
If not, explain ______________
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Did you suffer from post-partum depression?
______________________________________________________________________________
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What do you expect will be the impact on your children of your surrogacy?
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Why do you want to be a surrogate?
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Will you allow the prospective parents to be involved during the pregnancy?
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Will you allow the prospective parents to be present at the delivery?
______________________________________________________________________________
Are you willing to undergo an extensive physical examination and psychological assessment before entering into the surrogacy arrangement?
______________________________________________________________________________
Do you have health insurance? ____________________________________________________
Are you willing to execute a surrogacy contract that dictates certain behaviors in which you must engage or from which you must refrain during the pregnancy?
______________________________________________________________________________
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Are you willing to relinquish all claims to the child that is born as a result of the surrogacy arrangement?
______________________________________________________________________________
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