| Ethnicity | |
Primary Ethnicity | |
| Secondary Ethnicity | |
Religion | |
| Marital Status | |
Years of Marriage | |
| Experienced Marriage Issues | |
Months of Separation | |
| Reasons for Separation | |
———— | |
| Living with Any Partner | |
Months of Living with Current Partner | |
| Height (ft/inch) | |
Height (cm) | |
| Weight (LB) | |
Body Shape | |
| Blood Type | |
Blood RH Factor | |
| Any Conviction of Misdemeanor or Felony | |
Conviction Details | |
| Any Experience of Serious Accident or Crime | |
Experience Details | |
| Any DES Medication by Your Mother While Pregnant with You | |
Any Tattoo or Body Piercing in Last 18 Months | |
| Ever Placed a Child up for Adoption | |
Details of Placing for Adoption | |
| Ever Cared for a Foster Child | |
Child Fostering Details | |
| Having Driver License | |
Having Gun/Weapon at Home | |
| Owning Car | |
Car Insured | |
| Public Transportation Accessible | |
———— | |
| Family Genetic Disease | |
Family Genetic Disease Details | |
| Health Insured | |
Health Insurance Provider | |
| Prior Gestational Carrying | |
Past Gestational Carryings | |
| Date of the Last Gestational Carrying | |
IVF Clinic for the Last Gestational Carrying | |
| Prior Egg Donor | |
Past Egg Donations | |
| Last Egg Donation Date | |
———— | |
| Gestational Carrying Restriction | |
Gestational Carrying Restriction Details | |
| Smoking | |
Years of Smoking | |
| Drinking | |
How Often of Drinking | |
| Anyone Living with You Smoking | |
Anyone Living with You Excessively Drinking | |
| Medication Taking | |
Medication Taking Details | |
| Any Medical Issue | |
Medical Issue Details | |
| Any Eating Disorder | |
Eating Disorder Details | |
| Any Drug or Alcohol Abuse | |
Drug or Alcohol Abuse Details | |
| Advised to Limit Use of Alcohol or Drug | |
Failed to Take Advised Medical Test or Procedure | |
| Ever Taken IV (Intravenous Therapy) Drug | |
———— | |
| Prior Allergy | |
Prior Allergy Details | |
| Prior Chronic Problem | |
Prior Chronic Problem Details | |
| Prior Infectious Disease | |
Infectious Disease in Past 5 Years | |
| Infectious Disease 5 Years Ago | |
———— | |
| Prior Surgery | |
Surgery in Past 5 Years | |
| Surgery 5 Years Ago | |
———— | |
| Prior Hospitalization (Other than Surgery) | |
Prior Hospitalization in Past 5 Years | |
| Prior Hospitalization 5 Years Ago | |
———— | |
| Prior Postpartum Depression | |
Prior Postpartum Depression Details | |
| Prior Mental Issue | |
Mental Issues | |
| Mental Treatment in Past 6 Months | |
Mental Treatment 6 Months Ago | |
| Prior Blood Transfusion | |
Prior Blood Transfusion Details | |
| Prior Blood Donation Rejection | |
Prior Blood Donation Rejection Details | |
| Currently Pregnant or Breast-feeding | |
Average Period Interval (Days) | |
| Typical Period Days | |
Bleeding between Periods | |
| Menstrual Cycle | |
Irregular Menstrual Cycle Reasons | |
| Last Pap Smear Date | |
Last Pap Smear Normal? | |
| Abnormal Pap Smear Details | |
———— | |
| Ever Diagnosed to be Infertile | |
Prior Infertility Treatment | |
| Prior Infertility Treatment Details | |
———— | |
| Any Ovarian or Uterine Cysts | |
Ovarian or Uterine Cysts Details | |
| Any Prior Reproductive Illness | |
Prior Reproductive Illness | |
| Prior Reproductive Illness Treatment | |
———— | |
| Prior Pregnancy | |
Number of Prior Pregnancy | |
| Years of Prior Pregnancy | |
———— | |
| Prior Miscarriage | |
Number of Prior Miscarriage | |
| Years of Prior Miscarriage | |
———— | |
| Prior Abortion | |
Number of Prior Abortions | |
| Years of Prior Abortions | |
———— | |
| Prior stillbirth | |
Number of Prior Stillbirths | |
| Years of Prior Stillbirths | |
———— | |
| Prior Delivery | |
Number of Prior Deliveries | |
| Years of Prior Deliveries | |
Details of Delivered Babies | |
| Prior Pregancy with Birth Defect | |
Details of Prior Pregancy with Birth Defect | |
| Sexually Active | |
Sexual Contacts | |
| More than One Sexual Partner | |
Months with Current Partner | |
| Current Relationship Monogamous | |
Number of Partners in Past 1 Year | |
| Any Sexual Contact with Stranger | |
———— | |
| Any STD Partner | |
STD Partner Details | |
| Birth Control Pills Taken/Taking | |
Birth Control Reasons | |
| Any Contraception in Past 6 Months | |
Contraception in Past 6 Months | |
| Details for IUD/Other | |
———— | |
| Why Gestational Carrier | |
Aware by Family | |
| Family Opinions | |
Expected Support from Family, Intended Parents, and Agent | |
| Any Parents not Carrying for | |
Non-Carrying Details | |
| Willing to Carry Twins | |
Willing to Carry Triplets | |
| Any Situation not to Abort Pregnancy | |
Situation Details | |
| Allowing Intended Parents to Attend Medical Appointments | |
Willing to Undergo Diagnostic Test for Birth Defects | |
| Willing to Abort in case of Serious Problem | |
Allow Intended Parents in Delivery Room | |
| Allowing Intended Parents to Notify Hospital of the Biological Mother | |
Allowing Names of Intended Parents on Birth Certificate | |
| Willing to Pump Breast Milk | |
Will Give Intended Parents Carried Child(ren) | |
| Keeping Contact with Delivered Child and Intended Parents | |
———— | |
