Surrogate General Information
Date
-
Month
-
Day
Year
Date
Full Name
Email
example@example.com
Date of Birth
-
Month
-
Day
Year
Date
Age
Hair Color
Eye Color
Height
Weight
Blood Type
RH Factor (+/-)
Marital Status
If married or in a committed relationship: How long have you been together?
Partner's name
Including yourself, how many people live in your home?
# of Adults
# of Children
Sons' Ages
Daughters' Ages
Are you vaccinated?
Yes
No
Are you a Canadian Citizen?
Yes
No
Do you have a valid Drivers License?
Yes
No
Do you own a car?
Yes
No
If yes, please provide the province
If no, do you have reliable transportation to appointments?
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Employment Information (Please list most recent first)
Employment Information (Please list most recent first)
Rows
Employer
Position
Dates-Employed
Your Current Income
Partner's Present Employer
Position
Partner's Income
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Medical History
What prescribed medications are you currently taking? (Please indicate dosage)
Are you willing to stop or switch to pregnancy safe medications?
Yes
No
What form of birth control are you currently using?
Menstrual Cycle
Age of onset
Usual duration
Cycle (day 1-day 1)
Pain or cramps?
Yes
No
Regular?
Yes
No
Please list all surgeries (including oral)
Rows
Type
When
Where
1
2
3
Have you ever had
Rows
Yes
No
Date
Description
Yes
No
Date
Blood Transfusion
German Measles
Mumps
Chicken Pox
Scarlet Fever
Diphtheria
Pneumonia
Rheumatic Fever
Heart Disease
Heart Murmur
Polio/Meningitis
Kidney Infections
Gonorrhea/Syphilis
Nervous Breakdown
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Surrogate Questionnaire
robyn@canadiansurrogacyoptions.com
Pregnancy History
Please list all pregnancies, including miscarriages
Please list all pregnancies, including miscarriages
Rows
Year
Sex
Weight
Hrs. of labor
Anesthesia
Complications
1
2
3
4
5
6
Please list number of
Pregnancies
Abortions
Miscarriages
Still births
Live births
Cesarean births
Personal History
Do you smoke?
Yes
No
If yes, how many cigarettes per day?
Do you consume alcoholic beverages?
Yes
No
If yes, how often?
Do you use illegal or legal drugs?
Yes
No
If yes, what type and how often?
Have you had any therapy with a psychiatrist or any other mental health professional?
Yes
No
Date
Explanation
Have you ever had any psychiatric hospitalization?
Yes
No
If yes, please explain:
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General Questions
Why do you want to become a Surrogate?
Please explain how you think surrogacy works
How do you expect the following people will react to you being a Surrogate?
Parents
Siblings
Children
Friends/Coworkers
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