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Surrogate Intake
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* Indicates required question
Email
*
Your email
First name
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Your answer
Last name
*
Your answer
Maiden/Former/Other name
*
Your answer
Phone number
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Your answer
Date of Birth
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MM
/
DD
/
YYYY
Country
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United States
Other
Street Address
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Your answer
City
*
Your answer
State
*
Your answer
Zip Code
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Your answer
County
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Your answer
Are you a US citizen or green card holder?
*
Yes
No
Relationship Status
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Single
Married
Divorced
In a Relationship
Domestic Partnership
Other
Length of relationship/marriage
Your answer
Height
*
Your answer
Weight
*
Your answer
Race/Ethnicity
*
Your answer
Preferred pronouns
She/Her/Hers
He/Him/His
They/Them/Theirs
Clear selection
Have you been a surrogate or egg donor before?
*
No
Surrogate
Egg Donor
Both
Are you, your partner/spouse, or any members of your family registered members of a Native American tribe?
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Yes
No
Total number of pregnancies
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1
2
3
4
5+
Total number of pregnancies resulting in live birth
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1
2
3
4
5+
Do you have physical custody of your own child/ren? If no, please provide details.
*
Your answer
Please list dates of all deliveries (month and year) of all the children you have given birth to.
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Your answer
How many weeks and days were each of your children delivered at?
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Your answer
What did each of your children weigh at delivery?
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Your answer
Please list any reproductive events (miscarriages, abortions, premature delivery or stillbirths) or diseases that you have experienced. Please indicate the date(s), complications, outcome, circumstances, etc.
*
Your answer
Do any of the children you gave birth to have any health problems? If so, please specify.
*
Your answer
Number of cesarian sections
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0
1
2
3
4+
Any pregnancy or delivery complications?
*
Your answer
Do you want to have any more children? If so, when?
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Your answer
Did you need any medical assistance to conceive your children? If yes, please explain:
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Your answer
Are you currently breastfeeding? If so, when do you plan to wean?
*
Your answer
Are you currently using birth control and if so, what type?
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Your answer
What is your occupation?
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Your answer
Are you or any of your household family members on any form of government assistance (WIC, Medicaid, food stamps, etc.)? If so, please give details as to what kind of assistance and who receives the benefits.
*
Your answer
Do you have health insurance? If so, what is the insurance company name?
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Your answer
Is your health insurance or any health insurance for your family members part of a state or federally funded program such as Medicaid? If yes, please give details on the name of the program and who receives the benefits.
*
Your answer
Did you graduate high school / receive your GED?
*
Yes
No
Secondary Education and Years Attended / Degrees Achieved
*
Your answer
Do you have a spouse/partner?
Yes
No
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