Surrogate Questionnaire 

Please weigh yourself on the day you complete this form, include current weight from today.
Do you, (or anyone in your household) speak a language other than English? *
Are you currently in a monogamous relationship? *
2. Number of pregnancies *
Number of live births *
Number of miscarriages *
Number of abortions *
Please give the following information for all your children born
Please provide the name(s) and location(s) of each OB you saw for your pregancy(ies):
Please provide the name(s) and location(s) of each Hospital you delivered at:
Please give the following information for all surrogate children born:
6. Have you ever been seen by a doctor for infertility treatment? *
7. Have you ever been told of any gynecological problems (endometriosis, ovarian cysts, fibroids, abnormal pap smears, etc.)? *
8. Have you ever given birth to a baby with any sort of birth defect or genetic abnormality? *
Please check any of the following you’ve experienced with any of your pregnancies: *
Do your children live with you? *
Do any of your children have special needs? *
Have you ever placed a child for adoption? *
Do you smoke or vape? *
Do you drink alcohol or use recreational drugs? *
Have you ever been advised to limit your use of alcohol or any drugs? *
Do you have a history of eating disorders? *
Do you follow a particular food diet or have any special dietary restrictions or habits? *
Will your partner submit to lab tests that are FDA required? *
(These tests include sexually transmitted disease testing and drug testing.)
Is your partner on any federally controlled substance? *
Have you or anyone in your household ever been arrested and/or convicted of a crime/misdemeanor/felony? *
(Please note that it is standard practice for us to do background checks on all of our surrogates and their spouses and or/companions)
Have you traveled outside of the U.S. in the last 6 months? *
Do you plan on traveling outside of the U.S in the next 6-8 months? *
Do you have any issues with sleeping? *
Do you own and drive a car? *
Do you have automobile insurance? *
Do you have a valid driver’s license? *
Have you ever been formally or informally diagnosed with any mental health issue? *
(For example depression, anxiety, bipolar disorder)
Have you ever been hospitalized for a mental health issue? *
Do you currently or have you ever taken medication for a mental health issue? *
Have you ever been or are you currently participating in counseling or psychotherapy? *
Has anyone in your family ever had a mental or nervous disorder such as depression, anxiety, alcoholism or drug abuse? *
Were you ever involved in a relationship where you experienced domestic violence? *
Do you use non-prescription medications (such as Tylonel, Advil, allergy/cold medication, etc.)? *
Blood type: *
RH factor (+/-): *
Do you currently have any allergies? *
Do you currently have any medical problems or conditions? *
Have you ever had surgery performed or been hospitalized overnight for any reason within the past 5 years? *
Have you ever been tattooed or had a non-sterile skin piercing procedure in the last 12 months? *
(If yes, you may be required to provide a copy of the license from the facility)
Have you ever been refused as a blood donor? *
Please indicate whether you have had any of the following conditions or diseases: *
Have you or your partner ever tested positive for HepB or HepC antibodies or antigen (IgG or IgM)? *
Have you or your partner ever tested positive for HepB or HepC antibodies or antigen (IgG or IgM)? *
Have you been immunized for Hepatitis B? *
(If yes, be prepared to provide documentation)
Are you at risk for AIDS? *
To your knowledge, have any of your sexual partners in the last 5 years been sexually active with anyone in the high risk group for HIV/AIDS? *
Are you currently employed? *
(Paystubs will be necessary to verify when matched with Intended Parents)
(Paystubs will be necessary to verify when matched with Intended Parents)
Do you have health insurance coverage? *
Is it a private/personal policy or through you or your spouse’s employer?
Are you or on any government assistance? *
Are you currently in school? *
Have you ever been a surrogate before? *
Were there any failed cycles (negative pregnancy tests or chemical pregnancies)?
Please rate on a scale of 1 – 5 the importance of the following factors in your decision to become a surrogate gestational carrier
(1 being not important, 5 being extremely important)
I enjoy being pregnant, but do not want any more children of my own: *
I need the income: *
Having a child for an infertile couple would bring me great happiness: *
Would you be willing to communicate through phone calls or Skype? *
If recommended by a physician, would you be willing to undergo CVS, amniocentesis or other diagnostic testing to determine the presence of birth defects? *
Are there any specific conditions in which you would not terminate a pregnancy? *
How many embryos are you in agreement to transfer at a time (1 or 2 or doctor recommendation) *
Do you think your OB/GYN would be supportive of you helping aspiring parents have a baby? *
1st time, inexperienced surrogates make a base fee of $40-45k. Are you agreeable to this amount? *
Is this negotiable?
The form may take a up to 60 seconds to process fully. When it is done, you will see a thank you page. Please only press the submit button once.
Please submit 4-5 photos of you and your family to