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.

 
 
 
 

Surrogate Application Form

 
 
GENERAL INFORMATION
Date : June 18, 2013
ft. in.        lbs.
               
Ethnic Origin:
      years     months
 
 

 
 
FERTILITY HISTORY
Number of Children:
Number of Pregnancies:
months
months
months
months
months
 
 

 
 
WORK HISTORY
(Please indicate if you are a homemaker.)
Occupation Dates of Employment Exposed to Chemicals or Gases?
 
 

 
 
ACADEMIC BACKGROUND
            
 
 

 
 
HEALTH INFORMATION
 

PAST MEDICAL PROBLEMS
Condition Date Surgery / Treatment Resolution
Recent Medications and Reasons for Taking Them:
If there is any additional information about your medical history that you feel we should be aware of please use the space provided below to explain:
Current Allergies:

Vision :                 Corrective Lenses?    

History of Drug / Alcohol Abuse?    

Please describe :

History of intravenous drug use?    

Has your lifestyle in any way put you at risk for AIDS?    

Psychotherapy :    

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

Have you or any of your sexual partner had :



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

Have you ever been arrested?      

If yes, what was the charge?
 
 

 
 
LIFESTYLE
Do you smoke?                 Number per day :
Alcoholic Beverages :                 Number per week :

Do you exercise?    

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 will you have 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?
  1st 2nd 3rd 4th 5th 6th
Full Term
Birth Weight
Months to Conceive
Complications
Caesarian
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?    

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?    

 
 

I certify that this information is correct.

Full name :
Date :