Prospective Surrogate Questionnaire - IARC Surrogacy

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PROSPECTIVE SURROGATE QUESTIONNAIRE

Complete this short questionnaire and a Surrogate Coordinator

will be in touch with you very soon.

If you are human, leave this field blank.

First Name* *

Last Name* *

Email* *

Cell Phone* *

Home Phone

Date of Birth* *

Address* *

City* *

State* *

ZIP/Postal* *

Relationship Status* *

Single

Married

Divorced

Widowed

Height* *

Weight* *

How did you hear about IARC?* *

Please tell us where you were referred from* *

Please tell us who referred you* *

Are you a registered member of an American Indian (Native American) tribe?* *

Yes

No

Are you raising at least 1 child in your home?* *

Yes

No

Please list the names and ages of your children.

Tobacco Use* *

No

Daily

Weekly

Occasional

Former User

How many alcoholic beverages do you consume in 1 week?* *

0-1

1-2

2-3

More than 3

Do you have a criminal record (including DUI, minor, etc.)?* *

Yes

No

*Note: a criminal background check is completed on all surrogates

Please list any criminal history (including DUI, minor, etc.)* *

Do you receive any of the following financial assistance?* *

Food Stamps

Medicaid

Cash Assistance/Welfare

WIC

SSI/SSDI

Public Housing

Other

None

.

Medical History

How many pregnancies have you had (including miscarriages)* *

What kind of delivery did you have?

Vaginal

Cesarean

Miscarriage

Abortion

First Pregnancy

What kind of delivery did you have?

Vaginal

Cesarean

Miscarriage

Abortion

Second Pregnancy

What kind of delivery did you have?

Vaginal

Cesarean

Miscarriage

Abortion

Third Pregnancy

What kind of delivery did you have?

Vaginal

Cesarean

Miscarriage

Abortion

Fourth Pregnancy

What kind of delivery did you have?

Vaginal

Cesarean

Miscarriage

Abortion

Fifth Pregnancy

What kind of delivery did you have?

Vaginal

Cesarean

Miscarriage

Abortion

Sixth Pregnancy

What kind of delivery did you have?

Vaginal

Cesarean

Miscarriage

Abortion

Seventh Pregnancy

What kind of delivery did you have?

Vaginal

Cesarean

Miscarriage

Abortion

Eighth Pregnancy

What kind of delivery did you have?

Vaginal

Cesarean

Miscarriage

Abortion

Ninth Pregnancy

What kind of delivery did you have?

Vaginal

Cesarean

Miscarriage

Abortion

Tenth Pregnancy

Have you had any pregnancy/delivery/postpartum complications? If so, please explain:

Please select any STDs you have had, if any:* *

None

Gonorrhea

Chlamydia

Herpes

HPV

Syphilis

Hepatitis B

Hepatitis C

OtherOther

Please check if you experience any of the following:* *

Anxiety

Depression

PTSD

Post-Partum Depression

Bipolar Disorder

None

Please explain if you checked any above:

Are you currently taking supplements or prescription medication?* *

Yes

I do not take any medications.

Have you taken any anti-depressants and/or anti-anxiety medications in the last 6 months?* *

Yes

No

*Note: a psychological evaluation is completed on all surrogates

Please list any medications you are currently taking:* *

If it were medically determined that the fetus had a chromosomal abnormality or a serious health defect and it did not affect your health, would you allow the Intended Parents to be the ones to make the choice to continue or terminate the pregnancy?* *

Yes

No

Would like to discuss further

Let us know if there are any specific questions you would like discussed prior to setting up an informational call.

What is your interest level in becoming a surrogate?* *

By submitting this questionnaire, I affirm that the facts set forth in it are true and complete. I understand that if I am accepted to the Gestational Carrier candidate list, any false statements, omissions, or other misrepresentations made by me on this application may result in my immediate dismissal.* *

Agree

Signature of Prospective Surrogate* *

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