Surrogacy Application

Surrogacy Application
Contact Information
Your Legal Name

First Name Last Name
Any other names used:
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Cell Phone Number

Area Code Phone Number
Alternate Phone Number

Area Code Phone Number
Email
example@example.com

Basic Demographics
Your Current Marital Status

Single, with no partner Single but in a committed relationship Married Engaged Divorced, with no new partner Divorced, but in a new committed relationship
When do you plan to marry?
Enter your height
Weight
Birth Date

Month Day Year
Race
Religion
Please indicate all languages that you can read and/or write and please also note how fluent you are in each of them.

Citizenship/Residency

The following questions are related to your citizenship and establishing what state you are a resident of. We use this information to confirm that you can legally enter into a surrogacy agreement.
What US state are you currently a resident of?
How long have you been a resident of this state?
Do you have a drivers license in this state?

Yes No
Do you also reside part-time in any other state?

Yes No
Please list what other state(s) you reside in part-time.
Please select which best describes your citizenship status as a US citizen.

I was born in the United States and am a US Citizen I have my green card and am a permanent resident of the United States I am in the United States on a visa but am a citizen of another country I have dual citizenship in the United States and another country I was not born in the United States but am a US Citizen
Do you have any plans to relocate or move out of your current state in the next 2 years?
Are you willing to travel outside of your area for a minimum of two appointments (medical screening and embryo transfer)?

Yes No

Education

Please answer the following questions about your personal education.
Highest Level of Education
Level of Education Completed
What degrees have you completed or are you currently working toward?
Have you reached your educational goals? If not, please elaborate on these.
What is the name of the high school you graduated from and what was your approximate GPA (grade point average) at graduation?
Are you still in school?

Yes No
Please list the name of all colleges you have attended to date.
Name of college you are currently attending:
How many hours per week do you attend classes?
Please explain your current weekly class schedule.
Do you hope to continue with classes during your surrogacy journey?

Yes No
When are you expected to graduate or complete the program?

Month Day Year
Date
Please explain how you would handle your coursework should the fertility physician require you to be on bedrest or restricted activity.

Finding the Perfect Match

Please answer the following surrogacy related questions thoughtfully so that we can try to find you the right match.
Why do you want to be a surrogate?
Do you personally know anyone who has been a surrogate before?

Yes No
If yes, who do you know?
What do you think will be the hardest part of being a surrogate?
What do you think will be the most rewarding aspect of being a surrogate?
Who would you consider being a surrogate for (check all that apply)?

Single Male who identifies as heterosexual Single Male who identifies as homosexual Single Female who identifies as heterosexual Single Female who identifies as homosexual Unmarried, cohabitating same-sex couple Unmarried, same-sex couple who live apart Unmarried, cohabitating heterosexual couple Unmarried, heterosexual couple who live apart Married, cohabitating heterosexual couple Married, heterosexual couple who live apart Married, cohabitating same-sex couple Married, same-sex couple who live apart Widow/Widower
Would you work with an Intended Parent who does not speak English?

Yes No
Please describe the type of relationship you want to have with your Intended Parent(s) during the pregnancy.
Do you have any special requests for the Intended Parent(s)? If so, please specific these requests.
Have you shared with all of your family members your decision to be a surrogate and are they supportive?
Is it important to you that your child/children meet and develop a relationship with the Intended Parent(s) you will be working with?

Yes No
What are your spouse/partners thoughts and concerns about your decision to be a surrogate?
Is your spouse/partner aware of their responsibilities in the medical process and willing to cooperate?

Yes No Not applicable, I don't have a current partner I'm not sure yet
Have you discussed with your spouse/partner the fact that you will need to abstain from sexual intercourse at times during the surrogate process?

Yes, and he is understanding and supportive Yes, and he expressed concerns about this No, we have not discussed this I do not have a partner at this time
What concerns do you have about being a surrogate?
Would you be willing to change your diet to accommodate a request or preference of the Intended Parent(s) such as eating only organic fruit and vegetables or avoiding fried or unhealthy foods?
What is the maximum number of embryos you would be comfortable with transferring in any one attempt?

Single Embryo Transfer only Double Embryo Transfer or Single Embryo is okay with me I am not sure. I need more information before I make a decision.
Are you willing to carry a twin pregnancy?

Yes No
Are you willing to carry a triplet pregnancy?

Yes No
Are you willing to agree to a fetal reduction to reduce a healthy triplet pregnancy to a twin pregnancy, if the Intended Parent(s) request this?

Yes No
Are you willing to agree to a fetal reduction to reduce a healthy twin pregnancy to a singleton pregnancy, if the Intended Parent(s) request this?

Yes No
Do you understand that fetal reduction is not performed often until 12+ weeks gestation?

Yes No
Do you understand how fetal reduction is done?

Yes No
Are you willing to undergo an amniocentesis if the Intended Parent(s) request this? Please elaborate.
Are you willing to undergo intrauterine surgery if a physician feels this will substantially improve the outcome or life of the offspring and the Intended Parent(s) request this? Please elaborate.
Are you willing to terminate a pregnancy (prior to 24 weeks gestation) if there is a severe abnormality or in the event of down's syndrome? Please elaborate on your feelings with regards to pregnancy termination including whether this decision would be the decision of the Intended Parent(s) along with the treating physician or if you would want to have a say in these kind of decisions.
Are you willing to reduce a multiple pregnancy (prior to 24 weeks gestation) if there is a severe abnormality or down syndrome in only one of the babies?
Are there any specific traits or qualities you are looking for in a match with your Intended Parents?
How can you reassure the Intended Parent(s) that you will not want to "keep" their baby?
Do you see any reason why you would change your mind or "back out" after being matched with Intended Parents?
Why do you feel this is the most appropriate time in your life to be a surrogate?
How can you reassure the Intended Parent(s) that you will take the utmost care of yourself and their baby while you are pregnant?
What would you like the Intended Parent(s) to know about you?
What kind of future contact do you desire after the birth of the child with the Intended Parent(s) and with the child or children born through this process? Do you want photos, updates about their development, etc.? If yes, how often?

Reproductive Health
Approximate Date of Last Pap Smear
Was your most recent pap smear normal?

Yes No
Have you ever had an abnormal pap smear?

Yes No
Do you have regular periods (every 28-30 days) every month?

Yes No
Please select all that describe your menstrual cycle:

I do not get monthly periods I often skip my period for several months at a time I have not had a period in over a year I do not get a period because I am breastfeeding I have PCOS and do not get regular periods as a result I have an IUD that keeps me from getting regular monthly periods
Please list any medical diagnoses you have received related to your skipped periods
How long have you been getting irregular periods?
Duration of Menses
Menses Flow
Do you experience PMS or related symptoms?

Yes No
If yes, please select all the symptoms you have experienced:

Mild Cramps Severe Cramps Headaches Mood Swings Exhaustion Anemia
Do you currently, or have you had in the past, any menstrual-related problems?

Yes No
If yes, please explain:
Are you currently using Birth Control?

Yes No
Currently Used Methods of Birth Control:

Birth Control Pills IUD Diaphragm Neuva Ring Condoms (Male or Female)
How long have you been using the above method(s)? (list times for each method)
Birth Control Methods used in the past

Birth Control Pills IUD Diaphragm Neuva Ring Condoms (Male or Female)
Do you have any problems tolerating Birth Control Pills?

Yes No I've never used Birth Control Pills

Pregnancies with no resulting children
How many abortions have you had?

None One Two Three Four Five Six or More
Please list the month and year of each abortion.
How many miscarriages have you had?

None One Two Three Four Five Six or More
How many weeks gestation were you with each miscarriage and do you have additional details you can share with regard to any special circumstances or complications you experienced that may have led to the loss?
How many stillborn children have you given birth to?

None One Two Three Four Five or More
How many weeks gestation were you when you had the stillborn birth(s) and do you have additional details you can share with regard to any special circumstances or complications you experienced or that the baby experienced that may have led to the loss(es)?

Previous Pregnancies
How many pregnancies have you had that resulted in a singleton birth (1 child)?

None One Two Three Four Five Six Seven More than Seven
How many pregnancies have you had that resulted in a twin birth (2 children)?

None One Two Three Four Five More than Five
How many pregnancies have you had that resulted in a triplet birth (3 children)?

None One Two Three More than Three
Singleton Pregnancy #1
Child's First Name Only
Were there any complications with this child? Did he/she require time spent in the NICU or get advanced care after birth?
What sex was this child identified as by the physician at birth?

Male Female
Date of Birth

Month Day Year
Date
Due Date

Month Day Year
Date
Gestational Weeks Carried
Surrogacy/Own
Weight of Baby at Birth
Hours of Labor
C-Section/Vaginal Delivery
Please list any complications or significant events in the pregnancy (or type 'none')
Were you placed on restricted activity or bed rest at any point during the pregnancy? If yes, please elaborate on the length of time you were restricted and the reason for the restrictions.
Please list any medications taken during this pregnancy and why they were prescribed (or type 'none')
Please list any medications you were given during labor and/or birth (or type 'none')
Please list any complications or difficulties you may have experienced during labor and/or birth (or type 'none')
Did you experience postpartum depression after this delivery?

Yes No
Did you work during this pregnancy? If so, what were you doing for work at the time and how many hours did you work a week on average? Also, please note at what point in the pregnancy you stopped working and any challenges you experienced.
Singleton Pregnancy #2
Child's First Name Only
Were there any complications with this child? Did he/she require time spent in the NICU or get advanced care after birth?
What sex was this child identified as by the physician at birth?

Male Female
Date of Birth

Month Day Year
Date
Due Date

Month Day Year
Date
Gestational Weeks Carried
Surrogacy/Own
Weight of Baby at Birth
Hours of Labor
C-Section/Vaginal Delivery
Please list any complications or significant events in the pregnancy (or type 'none')
Were you placed on restricted activity or bed rest at any point during the pregnancy? If yes, please elaborate on the length of time you were restricted and the reason for the restrictions.
Please list any medications taken during this pregnancy and why they were prescribed (or type 'none')
Please list any medications you were given during labor and/or birth (or type 'none')
Please list any complications or difficulties you may have experienced during labor and/or birth (or type 'none')
Did you experience postpartum depression after this pregnancy?

Yes No
Did you work during this pregnancy? If so, what were you doing for work at the time and how many hours did you work a week on average? Also, please note at what point in the pregnancy you stopped working and any challenges you experienced.
Singleton Pregnancy #3
Child's First Name Only
Were there any complications with this child? Did he/she require time spent in the NICU or get advanced care after birth?
What sex was this child identified as by the physician at birth?

Male Female
Date of Birth

Month Day Year
Date
Due Date

Month Day Year
Date
Gestational Weeks Carried
Surrogacy/Own
Weight of Baby at Birth
Hours of Labor
C-Section/Vaginal Delivery
Please list any complications or significant events in the pregnancy (or type 'none')
Were you placed on restricted activity or bed rest at any point during the pregnancy? If yes, please elaborate on the length of time you were restricted and the reason for the restrictions.
Please list any medications taken during this pregnancy and why they were prescribed (or type 'none')
Please list any medications you were given during labor and/or birth (or type 'none')
Please list any complications or difficulties you may have experienced during labor and/or birth (or type 'none')
Did you experience postpartum depression after delivery with this pregnancy?

Yes No
Did you work during this pregnancy? If so, what were you doing for work at the time and how many hours did you work a week on average? Also, please note at what point in the pregnancy you stopped working and any challenges you experienced.
Singleton Pregnancy #4
Child's First Name Only
Were there any complications with this child? Did he/she require time spent in the NICU or get advanced care after birth?
What sex was this child identified as by the physician at birth?

Male Female
Date of Birth

Month Day Year
Date
Due Date

Month Day Year
Date
Gestational Weeks Carried
Surrogacy/Own
Weight of Baby at Birth
Hours of Labor
C-Section/Vaginal Delivery
Please list any complications or significant events in the pregnancy (or type 'none')
Were you placed on restricted activity or bed rest at any point during the pregnancy? If yes, please elaborate on the length of time you were restricted and the reason for the restrictions.
Please list any medications taken during this pregnancy and why they were prescribed (or type 'none')
Please list any medications you were given during labor and/or birth (or type 'none')
Please list any complications or difficulties you may have experienced during labor and/or birth (or type 'none')
Did you experience postpartum depression after delivery with this pregnancy?

Yes No
Did you work during this pregnancy? If so, what were you doing for work at the time and how many hours did you work a week on average? Also, please note at what point in the pregnancy you stopped working and any challenges you experienced.
Singleton Pregnancy #5
Child's First Name Only
Were there any complications with this child? Did he/she require time spent in the NICU or get advanced care after birth?
What sex was this child identified as by the physician at birth?

Male Female
Date of Birth

Month Day Year
Date
Due Date

Month Day Year
Date
Gestational Weeks Carried
Surrogacy/Own
Weight of Baby at Birth
Hours of Labor
C-Section/Vaginal Delivery
Please list any complications or significant events in the pregnancy (or type 'none')
Were you placed on restricted activity or bed rest at any point during the pregnancy? If yes, please elaborate on the length of time you were restricted and the reason for the restrictions.
Please list any medications taken during this pregnancy and why they were prescribed (or type 'none')
Please list any medications you were given during labor and/or birth (or type 'none')
Please list any complications or difficulties you may have experienced during labor and/or birth (or type 'none')
Did you experience postpartum depression after delivery with this pregnancy?

Yes No
Did you work during this pregnancy? If so, what were you doing for work at the time and how many hours did you work a week on average? Also, please note at what point in the pregnancy you stopped working and any challenges you experienced.
Singleton Pregnancy #6
Child's First Name Only
Were there any complications with this child? Did he/she require time spent in the NICU or get advanced care after birth?
What sex was this child identified as by the physician at birth?

Male Female
Date of Birth

Month Day Year
Date
Due Date

Month Day Year
Date
Gestational Weeks Carried
Surrogacy/Own
Weight of Baby at Birth
Hours of Labor
C-Section/Vaginal Delivery
Please list any complications or significant events in the pregnancy (or type 'none')
Were you placed on restricted activity or bed rest at any point during the pregnancy? If yes, please elaborate on the length of time you were restricted and the reason for the restrictions.
Please list any medications taken during this pregnancy and why they were prescribed (or type 'none')
Please list any medications you were given during labor and/or birth (or type 'none')
Please list any complications or difficulties you may have experienced during labor and/or birth (or type 'none')
Did you experience postpartum depression after delivery with this pregnancy?

Yes No
Did you work during this pregnancy? If so, what were you doing for work at the time and how many hours did you work a week on average? Also, please note at what point in the pregnancy you stopped working and any challenges you experienced.
Singleton Pregnancy #7
Child's First Name Only
Were there any complications with this child? Did he/she require time spent in the NICU or get advanced care after birth?
What sex was this child identified as by the physician at birth?

Male Female
Date of Birth

Month Day Year
Date
Due Date

Month Day Year
Date
Gestational Weeks Carried
Surrogacy/Own
Weight of Baby at Birth
Hours of Labor
C-Section/Vaginal Delivery
Please list any complications or significant events in the pregnancy (or type 'none')
Were you placed on restricted activity or bed rest at any point during the pregnancy? If yes, please elaborate on the length of time you were restricted and the reason for the restrictions.
Please list any medications taken during this pregnancy and why they were prescribed (or type 'none')
Please list any medications you were given during labor and/or birth (or type 'none')
Please list any complications or difficulties you may have experienced during labor and/or birth (or type 'none')
Did you experience postpartum depression after delivery with this pregnancy?

Yes No
Did you work during this pregnancy? If so, what were you doing for work at the time and how many hours did you work a week on average? Also, please note at what point in the pregnancy you stopped working and any challenges you experienced.
Twin Pregnancy #1
Baby A First Name Only
Were there any complications with Baby A? Did he/she require time spent in the NICU or get advanced care after birth?
What sex was Baby A identified as by the physician at birth?

Male Female
Weight of Baby at Birth
Baby B First Name Only
Were there any complications with Baby B? Did he/she require time spent in the NICU or get advanced care after birth?
What sex was Baby B identified as by the physician at birth?

Male Female
Weight of Baby B at Birth
Date of Birth

Month Day Year
Date
Due Date

Month Day Year
Date
Gestational Weeks Carried
Surrogacy/Own
Hours of Labor
C-Section/Vaginal Delivery
Please list any complications or significant events in the pregnancy (or type 'none')
Were you placed on restricted activity or bed rest at any point during the pregnancy? If yes, please elaborate on the length of time you were restricted and the reason for the restrictions.
Please list any medications taken during this pregnancy and why they were prescribed (or type 'none')
Please list any medications you were given during labor and/or birth (or type 'none')
Please list any complications or difficulties you may have experienced during labor and/or birth (or type 'none')
Did you experience postpartum depression after delivery with this pregnancy?

Yes No
Did you work during this pregnancy? If so, what were you doing for work at the time and how many hours did you work a week on average? Also, please note at what point in the pregnancy you stopped working and any challenges you experienced.
Twin Pregnancy #2
Baby A First Name Only
Were there any complications with Baby A? Did he/she require time spent in the NICU or get advanced care after birth?
What sex was Baby A identified as by the physician at birth?

Male Female
Weight of Baby at Birth
Baby B First Name Only
Were there any complications with Baby B? Did he/she require time spent in the NICU or get advanced care after birth?
What sex was Baby B identified as by the physician at birth?

Male Female
Weight of Baby B at Birth
Date of Birth

Month Day Year
Date
Due Date

Month Day Year
Date
Gestational Weeks Carried
Surrogacy/Own
Hours of Labor
C-Section/Vaginal Delivery
Please list any complications or significant events in the pregnancy (or type 'none')
Were you placed on restricted activity or bed rest at any point during the pregnancy? If yes, please elaborate on the length of time you were restricted and the reason for the restrictions.
Please list any medications taken during this pregnancy and why they were prescribed (or type 'none')
Please list any medications you were given during labor and/or birth (or type 'none')
Please list any complications or difficulties you may have experienced during labor and/or birth (or type 'none')
Did you experience postpartum depression after delivery with this pregnancy?

Yes No
Did you work during this pregnancy? If so, what were you doing for work at the time and how many hours did you work a week on average? Also, please note at what point in the pregnancy you stopped working and any challenges you experienced.
Twin Pregnancy #3
Baby A First Name Only
Were there any complications with Baby A? Did he/she require time spent in the NICU or get advanced care after birth?
What sex was Baby A identified as by the physician at birth?

Male Female
Weight of Baby at Birth
Baby B First Name Only
Were there any complications with Baby B? Did he/she require time spent in the NICU or get advanced care after birth?
What sex was Baby B identified as by the physician at birth?

Male Female
Weight of Baby B at Birth
Date of Birth

Month Day Year
Date
Due Date

Month Day Year
Date
Gestational Weeks Carried
Surrogacy/Own
Hours of Labor
C-Section/Vaginal Delivery
Please list any complications or significant events in the pregnancy (or type 'none')
Were you placed on restricted activity or bed rest at any point during the pregnancy? If yes, please elaborate on the length of time you were restricted and the reason for the restrictions.
Please list any medications taken during this pregnancy and why they were prescribed (or type 'none')
Please list any medications you were given during labor and/or birth (or type 'none')
Please list any complications or difficulties you may have experienced during labor and/or birth (or type 'none')
Did you experience postpartum depression after delivery with this pregnancy?

Yes No
Did you work during this pregnancy? If so, what were you doing for work at the time and how many hours did you work a week on average? Also, please note at what point in the pregnancy you stopped working and any challenges you experienced.
Twin Pregnancy #4
Baby A First Name Only
Were there any complications with Baby A? Did he/she require time spent in the NICU or get advanced care after birth?
What sex was Baby A identified as by the physician at birth?

Male Female
Weight of Baby at Birth
Baby B First Name Only
Were there any complications with Baby B? Did he/she require time spent in the NICU or get advanced care after birth?
What sex was Baby B identified as by the physician at birth?

Male Female
Weight of Baby B at Birth
Date of Birth

Month Day Year
Date
Due Date

Month Day Year
Date
Gestational Weeks Carried
Surrogacy/Own
Hours of Labor
C-Section/Vaginal Delivery
Please list any complications or significant events in the pregnancy (or type 'none')
Were you placed on restricted activity or bed rest at any point during the pregnancy? If yes, please elaborate on the length of time you were restricted and the reason for the restrictions.
Please list any medications taken during this pregnancy and why they were prescribed (or type 'none')
Please list any medications you were given during labor and/or birth (or type 'none')
Please list any complications or difficulties you may have experienced during labor and/or birth (or type 'none')
Did you experience postpartum depression after delivery with this pregnancy?

Yes No
Did you work during this pregnancy? If so, what were you doing for work at the time and how many hours did you work a week on average? Also, please note at what point in the pregnancy you stopped working and any challenges you experienced.
Twin Pregnancy #5
Baby A First Name Only
Were there any complications with Baby A? Did he/she require time spent in the NICU or get advanced care after birth?
What sex was Baby A identified as by the physician at birth?

Male Female
Weight of Baby at Birth
Baby B First Name Only
Were there any complications with Baby B? Did he/she require time spent in the NICU or get advanced care after birth?
What sex was Baby B identified as by the physician at birth?

Male Female
Weight of Baby B at Birth
Date of Birth

Month Day Year
Date
Due Date

Month Day Year
Date
Gestational Weeks Carried
Surrogacy/Own
Hours of Labor
C-Section/Vaginal Delivery
Please list any complications or significant events in the pregnancy (or type 'none')
Were you placed on restricted activity or bed rest at any point during the pregnancy? If yes, please elaborate on the length of time you were restricted and the reason for the restrictions.
Please list any medications taken during this pregnancy and why they were prescribed (or type 'none')
Please list any medications you were given during labor and/or birth (or type 'none')
Please list any complications or difficulties you may have experienced during labor and/or birth (or type 'none')
Did you experience postpartum depression after delivery with this pregnancy?

Yes No
Did you work during this pregnancy? If so, what were you doing for work at the time and how many hours did you work a week on average? Also, please note at what point in the pregnancy you stopped working and any challenges you experienced.
Triplet Pregnancy #1
Baby A First Name Only
Were there any complications with Baby A? Did he/she require time spent in the NICU or get advanced care after birth?
What sex was Baby A identified as by the physician at birth?

Male Female
Weight of Baby at Birth
Baby B First Name Only
Were there any complications with Baby B? Did he/she require time spent in the NICU or get advanced care after birth?
What sex was Baby B identified as by the physician at birth?

Male Female
Weight of Baby B at Birth
Baby C First Name Only
Were there any complications with Baby C? Did he/she require time spent in the NICU or get advanced care after birth?
What sex was Baby C identified as by the physician at birth?

Male Female
Weight of Baby C at Birth
Date of Birth

Month Day Year
Date
Due Date

Month Day Year
Date
Gestational Weeks Carried
Surrogacy/Own
Hours of Labor
C-Section/Vaginal Delivery
Please list any complications or significant events in the pregnancy (or type 'none')
Were you placed on restricted activity or bed rest at any point during the pregnancy? If yes, please elaborate on the length of time you were restricted and the reason for the restrictions.
Please list any medications taken during this pregnancy and why they were prescribed (or type 'none')
Please list any medications you were given during labor and/or birth (or type 'none')
Please list any complications or difficulties you may have experienced during labor and/or birth (or type 'none')
Did you experience postpartum depression after delivery with this pregnancy?

Yes No
Did you work during this pregnancy? If so, what were you doing for work at the time and how many hours did you work a week on average? Also, please note at what point in the pregnancy you stopped working and any challenges you experienced.
Triplet Pregnancy #2
Baby A First Name Only
Were there any complications with Baby A? Did he/she require time spent in the NICU or get advanced care after birth?
What sex was Baby A identified as by the physician at birth?

Male Female
Weight of Baby at Birth
Baby B First Name Only
Were there any complications with Baby B? Did he/she require time spent in the NICU or get advanced care after birth?
What sex was Baby B identified as by the physician at birth?

Male Female
Weight of Baby B at Birth
Baby C First Name Only
Were there any complications with Baby C? Did he/she require time spent in the NICU or get advanced care after birth?
What sex was Baby C identified as by the physician at birth?

Male Female
Weight of Baby C at Birth
Date of Birth

Month Day Year
Date
Due Date

Month Day Year
Date
Gestational Weeks Carried
Surrogacy/Own
Hours of Labor
C-Section/Vaginal Delivery
Please list any complications or significant events in the pregnancy (or type 'none')
Were you placed on restricted activity or bed rest at any point during the pregnancy? If yes, please elaborate on the length of time you were restricted and the reason for the restrictions.
Please list any medications taken during this pregnancy and why they were prescribed (or type 'none')
Please list any medications you were given during labor and/or birth (or type 'none')
Please list any complications or difficulties you may have experienced during labor and/or birth (or type 'none')
Did you experience postpartum depression after delivery with this pregnancy?

Yes No
Did you work during this pregnancy? If so, what were you doing for work at the time and how many hours did you work a week on average? Also, please note at what point in the pregnancy you stopped working and any challenges you experienced.
Triplet Pregnancy #3
Baby A First Name Only
Were there any complications with Baby A? Did he/she require time spent in the NICU or get advanced care after birth?
What sex was Baby A identified as by the physician at birth?

Male Female
Weight of Baby at Birth
Baby B First Name Only
Were there any complications with Baby B? Did he/she require time spent in the NICU or get advanced care after birth?
What sex was Baby B identified as by the physician at birth?

Male Female
Weight of Baby B at Birth
Baby C First Name Only
Were there any complications with Baby C? Did he/she require time spent in the NICU or get advanced care after birth?
What sex was Baby C identified as by the physician at birth?

Male Female
Weight of Baby C at Birth
Date of Birth

Month Day Year
Date
Due Date

Month Day Year
Date
Gestational Weeks Carried
Surrogacy/Own
Hours of Labor
C-Section/Vaginal Delivery
Please list any complications or significant events in the pregnancy (or type 'none')
Were you placed on restricted activity or bed rest at any point during the pregnancy? If yes, please elaborate on the length of time you were restricted and the reason for the restrictions.
Please list any medications taken during this pregnancy and why they were prescribed (or type 'none')
Please list any medications you were given during labor and/or birth (or type 'none')
Please list any complications or difficulties you may have experienced during labor and/or birth (or type 'none')
Did you experience postpartum depression after delivery with this pregnancy?

Yes No
Did you work during this pregnancy? If so, what were you doing for work at the time and how many hours did you work a week on average? Also, please note at what point in the pregnancy you stopped working and any challenges you experienced.

Medical Concerns During Pregnancies

Please Click to indicate "Yes" if you experienced any of the following:
Anemia

Yes No
High Blood Pressure

Yes No
Borderline High Blood Pressure

Yes No
Pregnancy-Induced Hypertension

Yes No
Preeclampsia/Toxemia

Yes No
Protein in Urine

Yes No
Gestational Diabetes

Yes No
Placenta Previa

Yes No
Nausea

Yes No
If yes, please explain
Vomiting

Yes No
If yes, please explain
Swelling in feet, ankles or face

Yes No
Pre-term Labor (prior to 36 weeks)

Yes No
Pre-term Birth (prior to 36 weeks)

Yes No
Still Birth

Yes No
Physician-ordered Bed Rest

Yes No

Home/Auto
Number of Cars in Household
Are all the above cars insured?

Yes No
Do you have a dedicated running vehicle you drive or do you share a vehicle with someone else?

Yes, I have my own vehicle that I can drive at any time No, I do not have a vehicle of my own that is in running order Yes, I share a vehicle with another person and the car is only available to me at certain times
Have you ever had a DUI or DWI?

Yes No
Have you ever had your license revoked or suspended?

Yes No
If yes, please explain the reasons why this happened.
How many accidents have you been in where you were driving and were found at-fault?
How many accidents have you been in where you were driving but were not found at-fault?
How many speeding tickets have you received in the last 3 years?
How many tickets outside of speeding have you received in the last 3 years?
Employment History
Are you currently employed?

Yes No
Current Occupation/Position Held
Name of Current Employer
Location of Current Employer

Street Address

Street Address Line 2

City State / Province
Length of employment (years, months)
# of hours worked per week
Please describe your duties
Are you required to be on your feet for a prolonged period of time?

Yes No
Are you required to lift anything over 15 lbs?

Yes No
Are you ever required to travel for your job?

Yes No
What kind of travel is required?

Driving in my state only Driving in my state and into a neighboring state(s) Flying within my state Flying both within my state and in the Continental United States Flying in my state, in the Continental United States, and internationally
Please elaborate on how often you are asked to travel with your current occupation including months which may have heavier than usual travel requirements.
How will you manage the responsibilities of your job if you are asked to refrain from travel, are not allowed to leave the state, or are put on bed rest or restricted activity?
Do you get health insurance through your employer?

Yes No
Do you get short term disability provided through your employer?

Yes No I'm not sure
Do you qualify for FMLA (12 weeks of job protection) through your employer?

Yes No I'm not sure
Please record any additional sources of income you have at this time.
Does your partner work as well?

Yes No I don't have a partner
What is your partner's current occupation/position held?
What is your partner's length of employment (months/years)
Does your partner's occupation require his to travel regularly for overnight trips?

Yes No
If yes, how long is your partner gone on average every month?
How will you manage the needs of your family and the household if your partner is out of town and you are put on bed rest or restricted activity?
Do you get health insurance benefits through your husbands employer?

Yes No

Medical History

General
Usual Weight
Body Frame
Have you been immunized for Hepatitis B?

Yes No
Have you ever been a surrogate?

Yes No
How many times have you been a surrogate?
Have you ever been an egg donor?

Yes No
How many times have you been an egg donor?
Are you currently under the care of a physician or counselor?

Yes No
If yes, please explain the condition for which you are being treated.
Do you currently have any medical problems/concerns?

Yes No
If yes, please explain including dates
Please list any previous surgeries
Please list any allergies to medication
Do you have any other allergies?

Yes No
If yes, please explain including dates
Have you ever been hospitalized?

Yes No
If yes, please explain including dates
Have you ever had a serious illness?

Yes No
If yes, please explain including dates
Have you ever had a serious injury?

Yes No
If yes, please explain including dates
Do you have a history of anxiety or depression?

Yes No
If yes, please explain including dates
Have you ever been diagnosed with an eating disorder?

Yes No
If yes, please explain including dates
Have you ever been in an inpatient or outpatient psychiatric treatment program?

Yes No
If yes, please explain illness including dates in the program
Do you have a family history of mental illness?

Yes No
If yes, please list the illnesses including dates treated
Do you currently take any medications?

Yes No
Please list any medications you are currently taking and why (include aspirin, antacids, laxative, etc.)
Does your spouse/partner currently take any medications?

Yes No
Please list any medications your spouse/partner is currently taking and why (include aspirin, antacids, laxative, etc.)
Do you currently take a vitamin with folic acid (i.e. prenatal vitamins)?

Yes No

Personal Health History

Please select yes for any of the following health conditions you currently have or have had in your lifetime.

Select if you have/had this condition

Stroke

Heart Attack

Heart Murmur

Valve Disease or Heart Valve Defect

Heart Disease

Blockages in the Arteries

Coronary Artery Disease

Carotid Artery Disease

Peripheral Artery Disease (narrowing of the arteries other than those that supply the heart)

High Blood Pressure

Chest Pain

Palpitations (skipped beats) or Heart Arrhythmia

High Cholesterol

Rheumatic Fever

Pulmonary Embolism (A blockage in one of the pulmonary arteries in the lungs, usually from a blood clot)

Deep Vein Thrombosis (DVT)

Varicose Veins

Phlebitis (inflammation of a vein)

Other Heart Disorder or Disease

Anemia (not sickle cell)

Sickle Cell Anemia

Hemophilia/Heavy Bleeding Issues

Clotting Disorder/Blood Clotting Issues

Thombosis

Thalassemia

Leukemia

Immune Deficiency

Multiple Myeloma (cancer of the plasma cells)

Other Blood Disorder

Asthma

Emphysema

Tuberculosis

Lung Cancer

Esophageal Cancer

Wheezing or Shortness of Breath (non-asthma related)

Snore

Pneumonia

Pulmonary Hypertension

Pleurisy

Cystic Fibrosis

Chronic Obstructive Pulmonary Disease (COPD)

Other Lung Disease

Stomach or Intenstinal Ulcer

Gallbladder (Stones, Polyps, Infections)

Gallbladder Cancer

Pancreatitis

Pancreatic Cancer

Hepatitis A

Hepatitis B

Cirrhosis

Colon Cancer

Colon Polyps

Colorectal Cancer

Ulcerative Colitis

Crohn's Disease

Intenstinal Cancer

Jaundice

Celiac Disease

Gastric Cancer

Liver Cancer

Familial Adnenomatous Polyposis (FAP)

Any other cancer/problem of digestive system

Diabetes Mellitus

Hypoglycemia

Thyroid Cancer

Thyroid Disease or Condition (including hyper/hypo thyroidism)

Goiter

Adrenal Dysfunction or Disorder

Gaucher's Disease

Cushing's Syndrome

Hyperparathyroidism

Other Metabolic/Endocrine Concerns

Multiple Miscarriages

Difficulty Getting Pregnant or Infertility

Polycystic Ovarian Syndrome

Death of Newborn Baby

Stillborn

Premenstrual Dysphoric Disorder (PMDD)

Endometriosis

Uterine Fibroids

Ovarian Cysts

Ovarian Cancer

Uterine Cancer

Cervical Cancer

Endometrial Cancer

Vaginal Cancer

Lack of Menstrual Cycle/Amenorrhea

Premature Ovarian Failure

Vulver Cancer

Other Reproductive Concerns or Diseases

Gaucher's Disease

Wilson's Disease

Huntington's Disease

Creutzfeldt-Jakob Disease

Alzheimer's Disease

Multiple Sclerosis (MS)

Parkinson's Disease

Dyslexia

Attention Deficit Disorder (ADD) or Attention Deficit Hyperactivity Disorder (ADHD)

Intellectual Disability (Difficulty Communicating, Learning, and/or Retaining Information)

Autism or related Autistic Spectrum Disorder/Aspergers Syndrome

Other Learning Disorders (Dyscalculia, nonverbal learning disability, dysgraphia)

Numbness or Weakness in the Body or Muscles

Loss of consciousness (Black-out spells)

Dizziness/Lightheadedness

Impaired Memory, Confusion or Dementia

Epilepsy or Seizures

Hereditary Spastic Paraplegia

ALS/Lou Gehrig's Disease

Spina Bifida

Brain Cancer

Migraine Headaches

Neurodevelopmental Disorder

Myasthenia Gravis

Other Diseases of Nervous Systems

Schizophrenia

Bipolar or Manic Depressive

Mood Disorder

Depression

Anxiety/Panic Attacks

Obsessive Compulsive Disorder

Eating Disorder

Body Dysphormic Disorder

Borderline Personality Disorder

Seasonal Affective Disorder

Self Harm Behaviors, Suicidal Thoughts, or Attempts

Excessive Drinking/Alcoholism

Drug Abuse, Misuse, or Addiction

Postpartum Depression/Baby Blues

Other Mental Health Condition

Muscular Dystrophy

Other chronic muscle disorder

Lupus

Deformity of the spine/Scoliosis

Osteoporosis

Dwarfism

Other Hereditary low back disease

Arthritis

Gout

Joint or Muscle Pains or Stiffness that Limit Mobility

Bone Cancer

Fibromyalgia

Cancer of the Nose or Nasal Cavity

Cancer of the Head or Neck

Cancer of the Mouth or Throat

Cancer of the Eye

Cancer of the Lymph Nodes

Seasonal Allergies - Pollen, Tree, Grass, Mold, Weeds, Dust or Flowers

Allergy to Animal Dander, Cat Hair, Bird Feathers, etc.

Allergy to Alcohol

Alergy to Sunlight

Allergy to Metals (Nickel, Metal, Gold, etc.)

Allergy to Latex

Allergy to Chlorine

Allergy to Insect/Bee Stings or Bites

Allergy to Hair Dye

Allergy to Laundry Detergent or Dryer Sheets

Allergy to Material (Lanolin/Wool, Down Feather Blankets, Leather, etc.)

Allergy to Iodine

Allergy to Medication

Other Allergies (non-food)

Allergy to Certain Spices (Cinnamon, Curry, etc)

Tree Nuts Allergy

Corn Allergy

Lactose Intolerance/Milk Allergy

Gluten Sensitivity/Intolerance

Soy Allergy

Peanut Allergy

Seafood (Fish/Crustacean) Allergy

Citrus Fruit Allergy (Grapefruit, Orange, Lemons, Limes, etc.)

Mustard Allergy

Seed Allergy (Poppy, Sesame, Sunflower)

Coffee Allergy

Beef. Pork, Lamb Allergy

Other Food Allergy

Medical History cont.

Dental History
Date of last Professional Teeth Cleaning (also known as prophylaxis)

Month Day Year
Date
Date of last Dental Exam

Month Day Year
Date
Do you have any pending dental care?

Yes No
Procedure(s) needed

Medical History cont.

Procedures and Conditions
Colposcopy

Yes No
If yes, please explain including dates
Cervical Conization

Yes No
If yes, please explain including dates
Cervical/Endo Biopsy

Yes No
If yes, please explain including dates
Biopsy of any kind

Yes No
If yes, please explain including dates
Mammogram

Yes No
If yes, please explain including dates
Vaginal Ultrasound

Yes No
If yes, please explain including dates
Colonoscopy

Yes No
If yes, please explain including dates
Electrocardiogram

Yes No
If yes, please explain including dates
Cortisone Injection

Yes No
If yes, please explain including dates
Asthma

Yes No
If yes, please explain including dates
Endometriosis

Yes No
If yes, please explain including dates
Pelvic Infection/Pelvic Pain

Yes No
If yes, please explain including dates
Ovarian Cyst

Yes No
If yes, please explain including dates
Chlamydia/Gonorrhea/Syphilis

Yes No
If yes, please explain including dates
Genital Herpes

Yes No
If yes, please explain including dates
Genital Warts

Yes No
If yes, please explain including dates
High Blood Pressure

Yes No
If yes, please explain including dates
Thyroid Disorder

Yes No
If yes, please explain including dates
Hepatitis

Yes No
If yes, please explain including dates
HPV/Condyloma

Yes No
If yes, please explain including dates

Lifestyle Questions
Have you gotten any new tattoos within the last 12 months?

Yes No
Have you gotten any new piercings within the last 12 months?

Yes No
How many tattoos do you have in total?
How many piercings do you have in total?
Have you had acupuncture treatment within the last 12 months?

Yes No
Would you be willing to have acupuncture if the fertility physician felt this was beneficial and the Intended Parent wanted this?

Yes No
Have you had any new vaccinations with the last two years?

Yes No
Have you participated in any kind of IV, IM, or subcutaneous drug use?

Yes No
Have you had any accidental contact with another person's blood or bodily fluid?

Yes No
Have you had an accidental needle stick?

Yes No
Have you had contact with blood that is known or is suspected to be infected with HIV, Hepatitis B, or Hepatitis C?

Yes No
Have you been sexually active with any partner who has had an STD or STI?

Yes No
Have you received a blood transfusion of blood or blood product?

Yes No
Have you received a Hepatitis B immune globulin injection?

Yes No
Have you traveled to a known Zika Virus affected area within the last 24 months?

Yes No
Please list all countries outside of the United States you have visited in the last 24 months.
Please list all countries outside of the United States you have plans to visit in the next 18 months.
How much exercise do you get on average in a week when not pregnant?

I don't really exercise and am not very active I don't really exercise but I run after my kids and that is a workout I exercise 1-2 times per week I exercise 3-4 times per week I exercise 5-7 times per week
Please select the types of activities you participate in regularly for exercise. Check all that apply.

Running Walking Hiking Swimming Weight Training Cycling Cross Fit Yoga Pilates Dancing Skateboarding Surfing Horseback Riding Golfing Volleyball Tennis Basketball Water Polo High Impact Cardio Rollerskating Skiing/Snowboarding Low Impact Cardio Ice Skating Jumping/Trampoline
Please describe your typical exercise routine during pregnancy.
Are you willing to limit this routine if asked to do so by the physician or the Intended Parents?

Yes No
How would you describe your daily diet?
What do you usually eat for breakfast?
What do you usually eat for lunch?
What do you usually eat for dinner?
What kind of snacks do you enjoy?
What beverages do you consume regularly in the week?
What is your average daily intake of water?

1 glass - 8 oz. 2 glasses - 16 oz. 3 glasses - 24 oz. 4 glasses - 32 oz 5 glasses - 40 oz. 6 glasses - 48 oz. 7 glasses - 56 oz. 8 glasses - 64 oz. More than 8 glasses - 64 oz+
Do you have any severe food allergies? If yes, please elaborate.
Do you have any dietary restrictions or things you will not eat for religious reasons or simply out of personal preference? Please note if you are vegan, vegetarian, kosher, etc.
Please describe your diet during pregnancy.
Do you drink caffeine?

Yes No

Surrogacy Application

Contact Information

Basic Demographics

Citizenship/Residency

Education

Finding the Perfect Match

Reproductive Health

Pregnancies with no resulting children

Previous Pregnancies

Singleton Pregnancy #1

Singleton Pregnancy #2

Singleton Pregnancy #3

Singleton Pregnancy #4

Singleton Pregnancy #5

Singleton Pregnancy #6

Singleton Pregnancy #7

Twin Pregnancy #1

Twin Pregnancy #2

Twin Pregnancy #3

Twin Pregnancy #4

Twin Pregnancy #5

Triplet Pregnancy #1

Triplet Pregnancy #2

Triplet Pregnancy #3

Medical Concerns During Pregnancies

Home/Auto

Employment History

Medical History

Personal Health History

Medical History cont.

Medical History cont.

Lifestyle Questions