The Surrogacy Program
Shelley B. Smith M.A., M.F.C.C.

4184 Colfax Ave.
Studio City, CA 91604
Fax: (818) 506-9763 Phone: (818) 506-9300

Surrogate Information

The information contained on this page will be kept confidential. Information in "Surrogate Application Form" will be shown with discretion to prospective recipients.

 

 
 
Name :
Street Address :
City, State, ZIP :
Home Phone :
Cell Phone :
Work Phone :
Email Address :
Preferred Means of Contact :
Age / Birth Date :
Marital Status and Length :
Name of Spouse or Significant Other :
Cell Phone :
Work Phone :
In case of emergency notify :
Relationship :
Phone # :

Who referred you?
Employer :
Primary Health Ins. Co. :
Life Ins. Co. :
Do you own a car?
Drivers Lic. State, No., & Expiration :
Spouse's D.L. state, No., & Expiration :
Do you have automobile Ins.?
Have you been a surrogate before?
 
 

Surrogate Application Form

 
 
GENERAL INFORMATION
Date : July 04, 2008
Surrogate's First Name :
Age :       Height :       weight :
Build :       Heavy       Medium       Slight

Paternal :

Maternal :

Ethnic Origin :

Primary Language Spoken :
Other Languages :
Religion :

Married       Single       Committed Relationship

Divorced       Widowed       How Long?

Marital Status :

Name of Spouse or Significant Other :
Occupation of Spouse :
Previous relationship lasted :       months     years
 
 

 
 
FERTILITY HISTORY

# male :

ages :

# female :

ages :

Number of Children :

Year :

Duration :

Year :

Duration :

Year :

Duration :

Number of Abortions :

Number of Pregnancies :
 
 

 
 
WORK HISTORY
(Please indicate if you are a homemaker.)

Occupation

Dates of Employment

Exposed to Chemicals or Gases?

Are you currently working?      
What are your career goals?      
 
 

 
 
ACADEMIC BACKGROUND

High School (No. of Years) :

College (No. of Years) :

Major :       Degree :

Educational Goals :

 
 

 
 
HEALTH INFORMATION

Blood Type :       Positive       Negative

General Health Condition :
Do you have any medical problems?       Yes       No

Please Explain :


PAST MEDICAL PROBLEMS

Condition
 

Date
 

Surgery /
Treatment

Resolution
 

Recent Medications and Reasons for Taking Them :
Current Allergies :      

Vision :     Poor     Good             Corrective Lenses?     Yes     No

History of Drug / Alcohol Abuse?     Yes     No

Please describe :

History of intravenous drug use?     Yes     No

Has your lifestyle in any way put you at risk for AIDS?     Yes     No

Psychotherapy :     Yes     No

Describe when and why :
Present Form(s) of Birth Control :      

Have you or any of your sexual partner had :
Chlamydia
Venereal Warts
Herpes
HIV

Other Sexually Transmitted Diseases :    
 
 

 
 
FAMILY / PATIENT PSYCHIATRIC HISTORY
Please specify self, parents, grandparents, siblings, aunts, uncles, etc.

Has there been any of the following in your family?

Suicide / Attempted Suicide :
Psychiatric Hospitalization :
Psychiatric Treatment :
Nervous Breakdown :
Depression :
Hyperactivity :
Schizophrenia :
Alcoholism :
Mental Retardation :
Criminal Convictions :
Epilepsy (If yes, was it due to head injury or CNS problem?)

Have you ever been arrested?       Yes     No

If yes, what was the charge?
  
 

 
 
LIFESTYLE
Do you smoke?     Yes     No             Number per day :
Alcoholic Beverages :     Yes     No             Number per week :

Do you exercise?     Yes     No

Types :     How Often?
Hobbies / Interests :      
 
 

 
 
PERSONALITY
Please describe your personality and character :
Why do you want to be a surrogate?
What message would you like to pass on to the prospective parents?

What kind of support do you expect from the following people in your life?

Your husband / boyfriend :
Your own parents :
Friends / co-workers :
What qualities would you consider most important in choosing a recipient couple?
How would you respond if the child wanted to meet you?
Would you like to have the couple in the delivery room?
Is there anything else you need from the program in order to do this?
Has your weight changed dramatically in the last five years? If so, why?

   

Full Term

Birth Weight

Months to Conceive

Complications

Caesarian

1st

2nd

3rd

4th

Please explain any birth / pregnancy complications : (premature, toxemia, gestational diabetes, placenta previa, bedrest ordered by doctor)
Did you need any medical help conceiving your children?

Did you take more than six months in conceiving your children?


If there was a serious problem with the pregnancy and the prospective parents wanted to consider abortion, would you be willing to abort?     Yes     No

Do you and your partner understand that, unless you have had a tubal ligation or unless your partner has had a vasectomy, you must agree to abstain from sexual activity while attempting to achieve a pregnancy for the couple?     Yes     No

 
 

I certify that this information is correct.

Full name :
Date :