Surrogate Questionnaire · Web viewC-section Fee $2,500 Loss of Reproductive Organs Fee: Partial...

SURROGATE QUESTIONNAIRE

GENERAL INFORMATION

Date:

First Name: ${First_Name}

State of residence: Closest major airport:

PERSONAL/PHYSICAL INFORMATION

Age: Birth date:

Height: Weight:

Race (s): Ethnic background (s):

Religious affiliation(s):

Are you a U.S. Citizen? Yes No

Have you ever lived in another country? Yes No

If yes: Country: Dates:

Country: Dates:

Country: Dates:

What languages do you speak/write?

Date(s) of ALL of your marriages:

Date(s) of ALL of your divorces:

200 W Madison Street, Suite 2100· Chicago, IL 60606Tel: 312.277.4008 | [email protected]

www.FamilySourceSurrogacy.com

COMPENSATION/BENEFITS INFORMATION

NOTE: Can this note be included on the online form, but NOT populated into this word document file!?

Please let us know what you will be requesting for your compensation package. The amounts are pre-filled

with “average” values requested by our surrogates, but you are free to alter any of these numbers to fit your

needs and personal comfort level.

INCLUDE THIS NOTE:

Compensation and benefits request for this surrogacy journey:

Amount:Base Compensation $35,000Start of Medication Fee (per cycle) $500Mock Cycle or Cancelled Cycle Fee $500Embryo Transfer Fee (per transfer) $750Monthly Allowance (to start with start of medications) $200Maternity Clothing Allowance (paid at 14 weeks):SingletonMultiples

$750$1,000

Multiple Fee (per additional fetus) $5,000Invasive Procedure Fee (per invasive procedure) $500Childcare $10/hourHousekeeping (when medically necessary) $90.00/weekC-section Fee $2,500Loss of Reproductive Organs Fee:Partial hysterectomyFull hysterectomy

$2,000$4,000

Lost wages for Surrogate:List hourly wage or annual salary to know current income

TBDVALUE

Lost wages for Surrogate’s husband (if applicable)List hourly wage or annual salary to know current income

TBDVALUE



INSURANCE INFORMATION

Do you have medical insurance? Yes No

If yes, is your insurance through:

Your employer

Your spouse/partner’s employer

The open market/Affordable Care Act plan

Government assistance plan

Name of Health Insurance Company:

Date effective:

Does your medical insurance include maternity coverage? Yes No

Yearly deductible? $

Coverage percentage? %

Co-pay amount? $ /per office visit

Monthly premium payment? $

Yearly maximum out-of-pocket expense? $

EMPLOYMENT INFORMATION

Are you currently employed? Yes No

Current occupation/position:

Start date with current employer:

Average number hours worked per week: hours



Hourly wage or annual salary:

Does your employer offer a short term disability plan? Yes No

If yes, are you currently enrolled in the plan? Yes No

EDUCATIONAL INFORMATION

Name and location of high school: Graduation date:

Did you attend college/university? Yes No

If yes, name and location: Graduation date:

Degree(s) and major(s)?

Please list any degrees you are currently pursuing:

Other licenses/certificates/areas of training, etc.:

SPOUSE/PARTNER INFORMATION

Current marital/relationship status:

Married Single, no partner Not married, but in a committed relationship

If married, date of your marriage:

If unmarried, but in a committed relationship, length of time in relationship:

Spouse/partner’s current occupation/position:

Spouse/partner's employment start date:

Average number hours worked per week? hours

Hourly wage or annual salary: $

Has spouse/partner ever seen a psychologist or any other mental health professional? Yes No

If yes, please list dates and circumstances:



Has spouse/partner ever been prescribed psychiatric medication(s)? Yes No


Has spouse/partner ever been hospitalized due to a psychiatric issue? Yes No


REPRODUCTIVE INFORMATION

Have you ever been a Surrogate? Yes No

If yes: Traditional Gestational

If yes, number of times:

If yes, list all outcomes:

Have you ever been an Egg Donor? Yes No

If yes, number of times:

If yes, list all outcomes:

Number of times you have been pregnant:

Number of children you have delivered:

Complete the following for each child you have delivered:

Gender Date of BirthMonths to Conceive

# Weeks at Delivery

Surrogate baby or your own?

Child #1 M F

Child #2 M F

Child #3 M F

Child #4 M F

Child #5 M F



Child #6 M F

Do you have physical custody of all your children? Yes No

If no, please explain:

Do any of your children have physical health problems? Yes No

If yes, please explain:

Do any of your children have psychological or behavioral problems? Yes No


Have you ever placed a child for adoption? Yes No

If yes, please list date(s) of adoption and explain:

Do you have any deceased children? Yes No

If yes, please list date(s) and explain:

Do you have any adopted or foster children? Yes No


Are you currently breastfeeding? Yes No

If yes, estimated completion date:

Excluding a surrogacy journey/egg donation, have you ever gone through fertility treatment? Yes

No


Have you ever delivered a premature baby? Yes No

If yes, list date(s) and weeks gestation at delivery:

Have you ever had a miscarriage? Yes No

If yes, list date(s) and weeks gestation at miscarriage:

Have you ever had a stillborn baby? Yes No

If yes, list date(s) and weeks gestation at birth:



Have you ever had an abortion? Yes No

If yes, list date(s):

Have you ever had any pregnancy and/or delivery complications? Select all applicable:

Pre-term labor High blood pressure Gestational diabetes

Placenta previa Other: No complications

If yes to any of the above, list date(s) and give details:

Have you ever had a caesarian section? Yes No

If yes, list date(s):

If yes, what was the reason for your C-section(s)?

Do you have regular menstrual cycles? Yes No

How many days per cycle? days

Current method of birth control and date begun:

Birth control pills Depo Provera Norplant Vasectomy

Condoms Diaphragm Patch Other

Contraceptive gel IUD Tubal ligation Not Sexually Active

Did your mother take diethylstilbestrol (DES) or any other prescription drugs while pregnant with you?

Yes No

PERSONAL HEALTH AND MEDICAL INFORMATION

Date of most recent OB/GYN visit:

Date of most current Pap Smear and results:

What is your blood type?



Do you have any allergies? Yes No

If yes, to what:

Do you currently take any prescription or over-the-counter medications? Yes No

If yes, please list all medications and the reason for taking them:

Have you ever been tested for HIV/AIDS? Yes No

If yes, list date(s) and results:

Have you ever suffered from depression? Yes No

If yes, please select the option(s) that best describe your depression:

Mild Moderate Severe Post-partum

Please select the option(s) that described your treatment:

Medication Counseling Exercise Life style modification

Have you ever seen a psychologist or any other mental health professional (for any reason)? Yes

No


Have you ever been prescribed psychiatric medication(s) for any reason? Yes No

Have you ever been hospitalized due to a psychiatric issue? Yes No

If yes, please list dates and explain:

Please describe your eating habits in detail. In example, specify if you are a vegetarian/vegan, how many

meals you eat in a typical day, what types of food you eat on a regular basis, etc.

Do you exercise? Yes No

If yes, frequency of exercise:

Have you ever had an eating disorder? Yes No


Outside of childbirth, have you ever been hospitalized or had a major illness? Yes No

If yes, please list date(s) and reason(s):



Have you ever had surgery (minor or major)? Yes No


Do you have any chronic medical conditions/concerns? Yes No

If yes, please list date(s) and condition(s):

Do you have any siblings who died in infancy or early childhood? Yes No


Do you smoke cigarettes? Yes No

Have you smoked any form of tobacco within the past year? Yes No

If yes, please list date(s):

Does anybody in your home smoke any tobacco product(s)? Yes No

If yes, please share who, which type of product, and frequency of use:

Do you drink alcohol? Yes No

If yes, how often: Daily Weekly Socially

Have you ever used illegal drugs? Yes No

If yes, please list date(s) and type of substance used:

Please check either “Yes” or “No” below accordingly:

Have either you or your spouse/partner ever been diagnosed with any of the following STD’s:

Gonorrhea Yes No Hepatitis B Yes No

Hepatitis C Yes No Herpes Yes No

HIV Yes No Genital warts/sores Yes No

Syphilis Yes No



Have you ever been diagnosed with any of the following conditions:

Anemia Yes No

Asthma Yes No

Back or neck problems Yes No

Beta strep Yes No

Cancer Yes No

Diabetes Yes No

Head injury Yes No

Heart problems Yes No

Hemorrhoids Yes No

High blood pressure Yes No

Irregular heartbeat Yes No

Kidney disease/infection Yes No

Kidney stones Yes No

Liver disease/infection Yes No

Migraine Yes No

Ovarian cysts Yes No

PID Yes No

Seizures Yes No

Thyroid problem Yes No

Tuberculosis Yes No

Uterine fibroid Yes No

Vaginal discharge Yes No

Varicose veins Yes No

If you answered “yes” to any of the above, please explain in detail, including dates:



LEGAL INFORMATION

Do either you or your spouse/partner have any legal claims/cases currently pending? Yes No


Please check either “yes” or “no” below accordingly:

Have you or your spouse/partner ever:

Been arrested or had conflicts with the law (include DUI arrests) Yes No

Been convicted of a felony Yes No

Been accused and/or convicted of child abuse or spousal abuse Yes No

Lost custody of a child Yes No

Been late with child support payments Yes No

Been turned down by an adoption agency Yes No

Been in a substance abuse program Yes No

Declared bankruptcy Yes No

If you answered “yes” to any of the above, please explain:



EXPECTATIONS FOR YOUR GESTATIONAL SURROGATE JOURNEY

If you have been a surrogate or egg donor in the past, please describe your feelings surrounding your

surrogacy and/or egg donation experience(s):

Is your partner and other family members aware of your plan to become a Surrogate? Yes No

Please share their response:

Who will support you emotionally during and after your surrogacy experience?

Do you have any concerns about sharing this information with your children? Yes No


Is there anybody in your life who is NOT supportive of your desire to become a Surrogate? Yes No


Please share your two primary reasons for your decision to become a Surrogate:

Please tell us all about you!

Describe your personality:

Tell us about your biggest strengths:



How do you enjoy spending your free time? What are your interests and hobbies?

Tell us how you envision feeling, on an emotional level, about carrying and delivering a child that will not be

your own:

Important Matching Details:

Do you want a: Single Embryo Transfer Double Embryo Transfer Either SET or DET

Will you carry twins if an embryo splits? Yes No

Will you carry triplets if an embryo splits? Yes No

Will you reduce in the event of a multiple pregnancy at the Intended Parent(s)’ request? Yes No

Will you terminate in the following situations at the Intended Parent(s)’ request?

Baby is diagnosed with a serious medical condition: Yes, will terminate No, will not

terminate

Baby is diagnosed with Down Syndrome: Yes, will terminate No, will not terminate

If requested by the Intended Parents (and recommended by a physician) would you be willing to have an

amniocentesis? Yes No

If no, please explain:

Are you looking for more of a “business” feel to the relationship between yourself and your Intended

Parent(s), or more of a friendship? Business Friendship

How much contact do you desire to have with your Intended Parents throughout the pregnancy? (Please be

specific as we aim to make the best match for you and your Intended Parents!)



Are you interested in continuing contact post birth? Yes No

Please share your thoughts:

Are you comfortable with your Intended Parents joining you at doctor appointments: Yes No

Are you comfortable with your Intended Parent(s) taking pictures during this journey? Yes

No

Please explain:

Are you comfortable with your Intended Parent(s) being in the delivery room? Yes No

Please explain:

What type of birth experience do you want?

Hospital/OB Hospital/Midwife Birth Center/Midwife Home Delivery/Midwife

If you selected anything other than “Hospital” is your selection a REQUIREMENT, or are you willing

to consider a hospital delivery? Requirement I’m flexible

Please expand, if you wish, on anything specific you envision during the birth experience:

Please describe the “ideal” Intended Parents with whom you’d like to work:

If you’d like, include a note to your future intended parents, here:



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Surrogate Questionnaire · Web viewC-section Fee $2,500 Loss of Reproductive Organs Fee: Partial...

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