Surrogate Mother Application
Identifying Information:
How were you referred to us?
Today's Date
-
Month
-
Day
Year
Date
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date
Age
Blood Type
Phone Number (Home)
-
Area Code
Phone Number
Phone Number (Cell)
*
-
Area Code
Phone Number
Phone Number (Work)
-
Area Code
Phone Number
Occupation
*
Are you a Florida Resident?
*
Yes
No
Are you a U. S. Citizen?
*
Yes
No
Do you have a valid Green Card?
Yes
No
Marital Status:
*
Single
Married
Divorced
Partner/Non- Marital
If Married, How Long:
Husband's Name:
Husband's Date of Birth:
-
Month
-
Day
Year
Date
Husband's Age:
Husband's Occupation:
Do you have Health Insurance?
*
Yes
No
If Yes, Name of Health Insurance?
Were you a previous Surrogate?
*
Yes
No
If Yes, when and what were the results:
PLEASE SUPPLY THREE CHARACTER REFERENCES
Please supply three letters from character references via email: mary@adoption-surrogacy.com
(1)Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
(2) Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
(3) Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Please let us know who you would be willing to work with:
A Married Couple
*
Yes
No
A Single Woman
*
Yes
No
A Single Man
*
Yes
No
A Gay/Lesbian Couple
*
Yes
No
Please explain why you wish to be a Surrogate Mother:
*
PHYSICAL CHARACTERISTICS:
Height:
*
Weight
*
Do you wear corrective lenses?
Yes
No
If so, for what problem?
Any Hearing Impairment?
Yes
No
If so, please explain
Do you have any tattoos or body piercings?
*
Yes
No
If yes, how long ago was your tattoo or body piercing?
BACKGROUND:
Race:
Ethnic Origin:
Mother's Race:
Father's Race:
Do you speak any other languages? If yes, please list.
Have you (or your husband/partner) ever been arrested?
*
yes
no
If yes, Please describe in detail- including the year, circumstances and charges:
What physical activities do you engage in?
Do you have any pets? If so, what kind and how many?
Describe any skills or talents that you have:
EDUCATION
High School or GED Completed?
Currently in College? Name of University
Pursuing a Degree in?
Completed College Degree:
Any Technical training or non-degree specialized courses?
Any Medical training or experience?
REPRODUCTIVE HEALTH
Age of first period:
*
Are your cycles regular? If not, please explain:
*
Interval between periods:
Describe any problems/special circumstances having to do with your reproductive health:
PREGNANCY HISTORY
Please indicate outcome as vaginal, C-section, Ectopic, Miscarriage or Termination
(1) Birth Year?
-
Month
-
Day
Year
Date
Outcome; Vaginal, C-Section, Miscarriage, Eptopic, or Termination?
Weeks Gestation
Weight of Baby
Any Complications?
If yes, please explain:
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PREGNANCY HISTORY (Continues)
Please indicate outcome as vaginal, C-section, Ectopic, Miscarriage or Termination
(2) Birth Year?
-
Month
-
Day
Year
Date
Singleton or Multiples?
Outcome; Vaginal, C-Section, Miscarriage, Eptopic, or Termination?
Weeks Gestation?
Weight of Baby?
Any Complications?
(3) Birth Year?
-
Month
-
Day
Year
Date
Singleton or Multiples?
Outcome; Vaginal, C-Section, Miscarriage, Eptopic, or Termination?
Weeks Gestation?
Weight of Baby?
Any Complications?
(4 )Birth Year?
-
Month
-
Day
Year
Date
Singleton or Multiples?
Outcome; Vaginal, C-Section, Miscarriage, Eptopic, or Termination?
Weeks Gestation?
Weight of Baby?
Any Complications?
(5) Birth Year?
-
Month
-
Day
Year
Date
Singleton or Multiples?
Outcome; Vaginal, C-Section, Miscarriage, Eptopic, or Termination?
Weeks Gestation?
Weight of Baby?
Any Complications?
Are you sexually active?
*
CURRENT BIRTH CONTROL METHOD:
*
For how long?
*
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HEALTH
Do you use nicotine?
*
cigarettes
vape
other
If yes, duration, type, and daily quantity:
Do you drink Alcoholic beverages?
*
Yes
No
If yes, How often?
Do now, or have you ever, used mind-altering drugs?
*
Yes
No
If yes, please explain:
How is your nutrition?
Poor
Average
Good
Excellent
Describe your nutritional habits, likes and dislikes:
Are you a vegetarian?
yes
no
Do you have any medical conditions or chronic illnesses?
*
yes
no
If yes, please explain:
List prescription and non-prescription medications that you take regularly:
Do you have any allergies?
yes
no
If yes, please explain:
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MEDICAL HISTORY
Have you had any surgeries?
*
Yes
No
If yes, please list any surgeries you have had and the dates:
Have you had a blood transfusion?
*
yes
no
If yes, how long ago?
Have you had radiation exposure?
*
yes
no
Please describe any other health issues that you have or have had:
Have you been immunized for:
*
Diptheria
Polio
Influenza (flu)
Small Pox
Measles, regular
Tetanus
Mumps
Whooping Cough
Rubella
None of the above
Other (please specify below)
Specify any other immunizations you have had:
FAMILY MEDICAL HISTORY
Please read the following list of medical problems carefully and indicate which ones you or one of your relatives have had. Please consider each condition for each family member: HEART AND BLOOD:
YOU
MOTHER
FATHER
SIBLING
Grandparents
other family
Stroke
Heart Attack
Heart Disease
Hardening of Arteries
High Blood Pressure
Anemia
Sickle Cell
Hemophilia
leukemia
HIV
Other Blood Disease
RESPIRATORY
YOU
MOTHER
FATHER
SIBLING
Grandparents
other family
Hayfever
Asthma
Emphysema
Tuberculosis
Lung Cancer
Pneumonia
Other Lung Disease
GASTRO INTESTINAL
YOU
MOTHER
FATHER
SIBLING
Grandparents
other family
Ulcer of stomach or duodenum
Gallstone
Hepatitis A
Hepatatis B
Other Liver Disease
Colon Cancer
Ulcerative Colitis
Crohn's Disease
Cystic Fibrosis
Intestinal Cancer
Other cancer of digestive system
METABOLIC ENDOCRINE
YOU
MOTHER
FATHER
SIBLING
Grandparents
other family
Diabetes Mellitus
Hypoglycemia
Thyroid Cancer
Thyroid Disease
Goiter
Adrenal Dysfunction or Disorder
Hyperactivity
URINARY
YOU
MOTHER
FATHER
SIBLING
Grandparents
other family
Kidney Disease
Other Disease of Urinary Tract
Rectal Disorder
GENITAL REPRODUCTION
YOU
MOTHER
FATHER
SIBLING
Grandparents
other family
Undescended Testicle
Hypospadiasis
Prostate
Uterine Fibroids
Ovarian Cancer
Cancer of Ovaries, Cervis, Uterus
NEUROLOGICAL
YOU
MOTHER
FATHER
SIBLING
Grandparents
other family
Migraines
Mental Retardation
Senility before age 50
Multiple sclerosis
Cerebral Palsy
Epilepsy
Hydrocephalus
Disorders of the Spinal Cord
Huntington's Chorea
Gaucher's Disease
Wilson's Disease
Other Disease of the Nervous System
MENTAL HEALTH
YOU
MOTHER
FATHER
SIBLING
Grandparents
other family
Schizophrenia
Manic Depression
Other mental health problems requiring hospitalization and/or medication
MUSCULAR, BONES & JOINTS
YOU
MOTHER
FATHER
SIBLING
Grandparents
other family
Muscular Dystrophy
Other chronic Muscle Disease
Lupus
Deformity of spine
Osteoporosis
Dwarfism
Hereditary Low Back Disease
Arthritis
Gout
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Next
PSYCHO/SOCIAL:
Religion:
What Religion were you born into?
What Religion are you now?
Are you an Atheist?
Yes
No
Are you an Agnostic?
Yes
No
How Religious are you now?
Very
Moderately
Occasionally Attend
Not at all
Please give a brief description of yourself and your personality:
**PLEASE ATTACH A FEW PICTURES OF YOU AND OF YOU AND YOUR FAMILY**
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