Surrogate Initial Screening Questionnaire
Last Name *
First Name *
Email Address *
Phone Number *
What is your current age? *
Date of Birth *
MM
/
DD
/
YYYY
Are you a smoker? *
Do you live in a smoke free home? *
Full Home Address Where You Will Reside During Pregnancy (Address, City, State, Zip) *
Any History of Mental Health Treatment for Yourself or Family? *
Have You Given Birth and are Raising at Least One Child?* *
Number of Children, Children's ages, and their living status? *
Are You Able to Provide Uncomplicated Pregnancies and Deliveries With Documentation in Prenatal and Delivery Record? *
Any Criminal History? *
Any History of Drug Usage? *
Any History of a Sexually Transmitted Disease of Any Kind? *
Do you have health insurance? *
Are you currently on any governmental assistance? *
How did you learn about Surrogacy Miracles & Consulting? *
Are You Able to Commit to the Responsibilities and Requirements to Be a Surrogate? *
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