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
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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
January
February
March
April
May
June
July
August
September
October
November
December
Month
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
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1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
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1982
1981
1980
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1972
1971
1970
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1950
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1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Race
African American or Black
Alaska Native
American Indian
Asian
Caucasian
Hispanic or Latino
Native Hawaiian or Pacific Islander
Religion
None
Agnostic
Atheist
Buddhist
Catholic
Christian
Hindu
Jewish
Muslim
Scientologist
Sikhism
Spiritual/New Age
Please indicate all languages that you can read and/or write and please also note how fluent you are in each of them.
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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?
Yes
No
Unsure
Are you willing to travel outside of your area for a minimum of two appointments (medical screening and embryo transfer)?
Yes
No
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Education
Please answer the following questions about your personal education.
Highest Level of Education
GED
High School Diploma
Some College
Associates Degree
Bachelors Degree
Masters Degree
MD
JD
PhD
Level of Education Completed
8th Grade
some High School
High School Diploma
Some College
Associates Degree
Bachelors Degree
Masters Degree
Ph.D.
J.D., M.D., D.D.S or Pharm. D.
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.
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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?
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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
1 Day
2 Days
3 Days
4 Days
5 Days
6 Days
7 Days
8 Days
9 Days
10 Days
11 Days
12 Days
13 Days
14 Days
15 or More Days
Menses Flow
None
Light
Moderate
Heavy
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
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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)?
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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
Surrogacy
Own
Weight of Baby at Birth
Hours of Labor
C-Section/Vaginal Delivery
C-Section
Vaginal
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
Surrogacy
Own
Weight of Baby at Birth
Hours of Labor
C-Section/Vaginal Delivery
C-Section
Vaginal
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
Surrogacy
Own
Weight of Baby at Birth
Hours of Labor
C-Section/Vaginal Delivery
C-Section
Vaginal
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
Surrogacy
Own
Weight of Baby at Birth
Hours of Labor
C-Section/Vaginal Delivery
C-Section
Vaginal
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
Surrogacy
Own
Weight of Baby at Birth
Hours of Labor
C-Section/Vaginal Delivery
C-Section
Vaginal
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
Surrogacy
Own
Weight of Baby at Birth
Hours of Labor
C-Section/Vaginal Delivery
C-Section
Vaginal
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
Surrogacy
Own
Weight of Baby at Birth
Hours of Labor
C-Section/Vaginal Delivery
C-Section
Vaginal
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
Surrogacy
Own
Hours of Labor
C-Section/Vaginal Delivery
C-Section
Vaginal
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
Surrogacy
Own
Hours of Labor
C-Section/Vaginal Delivery
C-Section
Vaginal
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
Surrogacy
Own
Hours of Labor
C-Section/Vaginal Delivery
C-Section
Vaginal
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
Surrogacy
Own
Hours of Labor
C-Section/Vaginal Delivery
C-Section
Vaginal
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
Surrogacy
Own
Hours of Labor
C-Section/Vaginal Delivery
C-Section
Vaginal
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
Surrogacy
Own
Hours of Labor
C-Section/Vaginal Delivery
C-Section
Vaginal
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
Surrogacy
Own
Hours of Labor
C-Section/Vaginal Delivery
C-Section
Vaginal
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
Surrogacy
Own
Hours of Labor
C-Section/Vaginal Delivery
C-Section
Vaginal
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.
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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
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Home/Auto
Number of Cars in Household
0
1
2
3
4
5
6
7
8
9+
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
Postal / Zip Code
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
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Medical History
General
Usual Weight
Body Frame
Extra-Small
Small
Medium
Large
Extra-Large
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?
1
2
3
4
5
6
7
8
more than 8
Have you ever been an egg donor?
Yes
No
How many times have you been an egg donor?
1
2
3
4
5
6
7
8
more than 8
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
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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
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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
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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
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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