Questionnaire: Surrogacy Application

Selecting the right surrogate mother can be a tough task. This questionnaire can help you determine if the woman are talking to is the right candidate. Fill in this questionnaire and show it to your attorney. Your attorney can then advise you of possible red flags and if you choose the candidate, draft the surrogacy agreement.

 

Name _______________________________________________________________________

 

Address _____________________________________________________________________

 

______________________________________________________________________________

 

______________________________________________________________________________

 

Date of Birth __________________________________________________________________

 

Telephone number (Home)______________ (Work) __________

 

E-mail address _________________________________________________________________

 

Employer Name: ______________________________________________________________

 

Employer Address:_____________________________________________________________

 

Post Held: _____________________________________________________________

 

Education ____________________________________________________________________

 

Marital Status _________________________________________________________________

 

If married, are you and your husband on the same page regarding your decision to become a surrogate mother? ______________________________________________________________________________

 

Height ________________________

 

Weight ________________________

 

Are you on any medication? Yes/No

 

If yes, list them

 

______________________________________________________________________________

 

______________________________________________________________________________

 

______________________________________________________________________________

 

______________________________________________________________________________

 

Have you been hospitalized or undergone any surgery in the past 10 years? Yes/No

 

If yes, list them

 

______________________________________________________________________________

 

______________________________________________________________________________

 

______________________________________________________________________________

 

______________________________________________________________________________

 

Are you suffering from any allergy or other health problem? Yes/No

 

If yes, list them

 

______________________________________________________________________________

 

______________________________________________________________________________

 

______________________________________________________________________________

 

______________________________________________________________________________

 

Are you suffering or have your suffered from any mental illness?Yes/No

 

If yes, list them

 

______________________________________________________________________________

 

Are you suffering from HIV or any other sexually transmitted diseases?Yes/No

 

If yes, list them

 

______________________________________________________________________________

 

 

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

 

If yes, please specify the results: Negative/Positive

 

Do you consume alcohol? Yes/No

 

If yes, how often

__________________________________________________

 

Do you consume illicit drugs? Yes/No

 

If yes, list them

 

___________________________________________________________

 

Do you smoke? Yes/No

 

If yes, how often

___________________________________________________________

 

 

Family Background

 

FatherMotherBrotherSister
Name
Whether alive
Age if aliveIf expired, age at the time of death
If death, cause of death
Medical/health problems if any

 

Children

 

NameAgeSexMedical/Health Problems if any

 

Were you at any time pregnant but could not carry the pregnancy to full term? Yes/No.

 

If yes, please explain

___________________________________________________________

 

Did you suffer from post-partum depression?

 

______________________________________________________________________________

 

______________________________________________________________________________

 

Will this surrogacy arrangement affect your children?

 

______________________________________________________________________________

 

______________________________________________________________________________

 

______________________________________________________________________________

 

______________________________________________________________________________

 

______________________________________________________________________________

 

______________________________________________________________________________

 

The reason(s) why you want to be the surrogate mother of our child

 

______________________________________________________________________________

 

______________________________________________________________________________

 

______________________________________________________________________________

 

______________________________________________________________________________

 

______________________________________________________________________________

 

______________________________________________________________________________

 

Prospective parents/father/mother can/can not be involved in the pregnancy

______________________________________________________________________________

 

______________________________________________________________________________

 

______________________________________________________________________________

 

Prospective parents/father/mother can/can not be present at the time of the birth of the child

______________________________________________________________________________

 

 

Willing to undergo the required medical and psychological tests: Yes/No

 

Health Insurance: Yes/No

If yes, provide details

____________________________________________________________________________

 

Willing to place accept restrictions on activities during pregnancy: Yes/No

______________________________________________________________________________

 

______________________________________________________________________________

 

______________________________________________________________________________

 

Waive all claim on the child once the child is born: Yes/No

Would you like to discuss your legal matter?

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