questionnaire

Questionnaire

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Basic Information

First Name

Last Name

Address

Phone

Education & Work History

Highest level of education

Actual height (Feet)

Actual height (Inches)

Actual weight? (Pounds)

BMI

BMI Rounded

Current Employer

Job Title

How many hours a week do you work?

Please describe your job duties:

Family Background & Support

Partner's name

Partner's age

Partner's occupation

Length of Relationship (Years)

(Months)

Criminal History

List ALL additional people living in your home including name, age, and relationship:

Who will watch your kids while you attend appointments associated with surrogacy such as Medical Screening, Embryo Transfer, and Delivery?

Please describe your support system and if they live close to you.

Who will drive you to the hospital?

Does anyone in your home smoke?

Have you or your partner taken any anti-depressants, anti-psychotics, or anti-anxiety medication in the last six (6) months?

Have you or your partner ever seen a psychologist, psychiatrist, or counselor?

If yes, please explain

Have you or your partner attempted or committed suicide?

If yes, please explain

Medical Information

What is your current method of birthcontrol (please include brand)?

What was the date of your last period?

Are you currently breastfeeding?

When was your last pap smear, what were the results?

Have you or a partner ever been diagnosed with an STD?

If yes, please explain

Have you been hospitalized in the past 12 month?

If yes, for what reason?

Have you had any surgeries in the past 12 months?

If yes, what is the name of the surgery you had?

Please list any medications you are taking:

Acceptance

Do you understand you are required to take medication and/or injections for several weeks (sometimes months) as part of the surrogacy process? (This will prepare your uterus for implantation and to help maintain the pregnancy.)

Preferences

Would you be willing to carry Twins?

Via split embryo or via 2 embryo transfer?

Would you and your husband (if you are married) agree to terminate the pregnancy if medically advised to due to health risks to you and/or the baby?

Would you and your husband (if you are married) agree to terminate the pregnancy at the parent's request if developmental abnormalities (e.g. Down syndrome, chromosomal abnormalities, absence of a limb or limbs, underdeveloped organ(s)) are detected?

Would you and your husband (if you are married) agree to reduce triplets to twins if advised by a doctor and agreed by the intended parents?

Would you be willing to work with IPs with HIV positive? (HIV positive IPs' sperms have been washed to safely extract the virus from the sperms before embryos were created)

Would you be willing to work with IPs with Hepatitis B positive?

Would you be willing to work with IPs with CMV positive?

Other

Are you currently working with another agency?

Have you ever worked with another agency?

Have you ever applied at another agency and been rejected/denied?

Explain:

Is there any additional information you would like us to know or think that we should be aware of?