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