Surrogacy Questionnaire
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Date of Birth
*
-
Month
-
Day
Year
Date
Place of Birth: City/Country
*
Current Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How did you hear about Eggvise?
*
Please Select
Kilmar - Nani Ramirez
Nataly Pagano
Kryssell Valoz
Alicia Ontiveros
Social Media: Facebook
Social Media: Google search
Social Media: Instagram
Personal
Ethnicity
*
Maternal Heritage (Where is your mother from?)
*
Paternal Heritage (Where is your father from?)
*
Are you adopted?
*
Yes
No
Please indicate your religion
*
Please Select
Catholic
Christianity
Islam
Hinduism
Buddhism
Judaism
Sikhism
Height
*
Weight
*
Eye Color
*
Please Select
Brown
Hazel
Green
Blue
Natural Hair Color
*
Black
Brown
Blonde
Red
Hair Texture
*
Straight
Curly
Wavy
Complexion
*
Fair
Olive
Medium
Dark
Do you have Freckles?
*
Corrective Dental?
*
Do you currently wear glasses?
*
Marital Status
*
Single
Married
Engaged
Divorced
Widowed
Are you a US Citizen or have permeant residency?
*
Yes
No
Are you legal in United States? Please explain
*
Where were you born?
*
What amount are you seeking as compensation?
*
We would love to get to know you a bit more. How would you describe your personality? Tell us how you see yourself and what makes you unique. This will help future parents get to know you better and understand a little more about who you are.
*
Have you been a surrogate in the past?
*
How many times?
*
Tell us, what motivates you to become a surrogate? We would love to know more about what inspires you to make this decision
*
What is your favorite type of food?*
*
If you could say something to Intended Parents, what message would you like them to know?
*
Education
Current Level of Education
*
Please Select
High school
Associate’s Degree
Bachelor’s Degree
Master’s Degree
Doctoral Degree
Certificates
Name of the College currently attending or attended
*
Major
*
If in US, College Grade Point Average (GPA)
*
Current Occupation
*
Do you have a learning disability?
*
Do you have any musical talents? If any, please list.
*
Do you play sports or exercise? please explain.
*
How often do you exercise?
*
OB-GYN
Do you have both of your ovaries?
*
At what age did you first experience your menstrual cycle?
*
Do you have a regular menstrual cycle? If not, please describe any irregularities
*
Current method of birth control.
*
Are you currently sexually active?
*
Have you ever been pregnant?
*
Did you experience any medical issues during your pregnancy? If so, please provide details.
*
How Many Children do you have?
*
Are you currently breastfeeding? If yes, please provide details.
*
Do you currently have or have you ever had any sexually transmitted infections (STIs)? If so, please specify if they were treated by a doctor.
*
Have you ever had an abortion? If so, please provide details.
*
Have you ever had a stillborn baby?
*
Have you experienced a miscarriage before?
*
Do you get a regular period?
*
Have you ever found a lump on your breast before?
*
Date of your last pap smear. (If none put N/A)
*
What were the results of your last pap smear?
*
Medical History
Have you received a COVID-19 vaccine? If yes, please specify the type of vaccine (e.g., Pfizer, Moderna, Johnson & Johnson) and the dates of vaccination, if known.
*
Are you currently treating any diseases? If so, please list.
*
Are you taking any prescription or over the counter medications? If yes, please explain
*
Have you been tested as a carrier of Thalassemia? If yes, please explain.
*
Have you been tested for being a Cystic Fibrosis carrier? If yes, please explain.
*
Have you been tested as a carrier for the Sickle Cell disease? If yes, please explain
*
Have you ever had any surgeries or significant medical treatments? Please provide details.
*
Have you had any complications during previous pregnancies or deliveries?
*
Are you willing to undergo regular drug and alcohol testing throughout the surrogacy process?
Yes
No
Have you gotten any tattoos in the past 12 months?
Yes
No
Have you had any piercings in the past 12 months?
Yes
No
Have you ever been diagnosed with cancer?
*
Yes
No
Do you have any birth defects?
*
Yes
No
Have you ever had any STI/STDs?
*
Yes
No
Have you ever had syphilis or gonorrhea?
*
Yes
No
Have you ever had hepatitis B or C?
*
Yes
No
Have you ever had a blood transfusion?
*
Yes
No
Have you ever been rejected for a blood transfusion?
*
Yes
No
Do you or any of your family members have a history of easily bruising or bleeding?
*
Yes
No
Have you ever had serious mental health issues?
*
Yes
No
Have you ever been clinically diagnosed with depression or bipolar disorder?
*
Yes
No
Have you ever taken antidepressants or anxiolytics? Explain why.
*
Do you have any allergies? If so, please specify.
*
Have you undergone any cosmetic surgeries in the past year? If so, please specify the type of surgery
*
Do you drink coffee? How often (daily or weekly)?
*
Do you drink alcohol? How often (daily or weekly)?
*
Do you smoke, vape, or use marijuana? How often (daily or weekly)?
*
Does your family have twins or triplets? Please specify
*
Do you or any of your family members have genetic disorders？
*
Do you or any of your family members have genetic disorders？
*
Do you have any direct family member with autism? please explain
*
Surrogacy Preferences
Are you willing to undergo a psychological evaluation as part of the surrogacy process?
*
Yes
No
Do you have any concerns or preferences about working with the intended parents (e.g., communication, involvement)?
*
Yes
No
Are you comfortable with breastfeeding/pumping for the baby after delivery?
*
Yes
No
Are you comfortable with a C-section if necessary?
*
Yes
No
Are you open to maintaining contact with the intended parents after delivery?
*
Yes
No
Would you be willing to undergo counseling with the intended parents if necessary?
*
Yes
No
Do you have any preferences regarding the intended parents (e.g., single, heterosexual, LGBTQ+)?
*
How do you feel about having the intended parents present during delivery? please explain
*
How do you feel about sharing updates and ultrasound images during pregnancy? please explain
*
What level of communication do you prefer with the intended parents (frequent, occasional, minimal)? please explain
*
Lifestyle and Support System
Do you have a stable living environment?
*
Yes
No
Do you follow any particular diet or lifestyle choices (e.g., vegan, gluten-free, etc.)?
Yes
No
Are you willing to abstain from smoking, drinking, and drug use during pregnancy?
*
Yes
No
Do you have a supportive partner, family, or friends who are willing to support you throughout the surrogacy process?
*
Yes
No
Will you have a support person (e.g., spouse, friend) attend appointments or be involved in the pregnancy process?
*
Yes
No
Are you willing to undergo regular medical screenings and appointments as required by the surrogacy program?
*
Yes
No
Do you work full-time or part-time? If so, what is your occupation? please explain
*
How would you describe your diet and exercise habits? please explain
*
Legal and Financial
Are you currently involved in any legal disputes or custody battles?
*
Yes
No
Do you have health insurance that will cover the pregnancy? If not, are you willing to obtain additional coverage?
*
Yes
No
Are you comfortable with the legal contracts required for surrogacy?
*
Yes
No
Are you currently receiving government assistance (e.g., Medicaid, food stamps, housing aid)?
*
Yes
No
Are you open to undergoing a criminal background check?
*
Yes
No
Do you have any history of legal issues (e.g., criminal charges, family law matters)?
*
Yes
No
Is there anything else you feel is important for us to know about you or your situation?
*
Yes
No
Family History
Mother - Current age
*
Age at death and cause of death (if applicable)
Health Conditions
*
Height
*
Eye Color
*
Brown
Hazel
Green
Blue
Natural Hair Color
*
Black
Brown
Red
Blonde
Occupation
*
Father - Current age
*
Age at death and cause of death (if applicable)
*
Health Conditions
*
Height
*
Eye Color
*
Brown
Hazel
Green
Blue
Natural Hair Color
*
Black
Brown
Red
Blonde
Occupation
*
Maternal Grandfather - Current age
*
Age at death and cause of death (if applicable)
*
Health Conditions
*
Height
*
Eye Color
*
Brown
Hazel
Green
Blue
Natural Hair Color
*
Black
Brown
Red
Blonde
Occupation
*
Maternal Grandmother - Current age
*
Age at death and cause of death (if applicable)
*
Health Conditions
*
Height
*
Eye Color
*
Brown
Hazel
Green
Blue
Natural Hair Color
*
Black
Brown
Red
Blonde
Occupation
*
Paternal Grandfather - Current age
*
Age at death and cause of death (if applicable)
*
Health Conditions
*
Height
*
Eye Color
*
Brown
Hazel
Green
Blue
Natural Hair Color
*
Black
Brown
Red
Blonde
Occupation
*
Paternal Grandmother - Current age
*
Age at death and cause of death (if applicable)
*
Health Conditions
*
Height
*
Eye Color
*
Brown
Hazel
Green
Blue
Natural Hair Color
*
Black
Brown
Red
Blonde
Occupation
*
Do you have siblings?
Yes
No
How many siblings do you have? Please specify.
*
Photo Uploads
Please make sure to upload at least 5 photos
Please provide 10-20 photos from different stages of your life, including a recent full-body photo. No group photos, as these will help intended parents in making their decision. A minimum of 10 photos is required
*
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