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Questionnaire: Surrogacy Application
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Deciding on the right surrogate mother is a challenging endeavor. The decision is fraught with emotional and legal implications. The following questionnaire can serve as a helpful tool in your determination of whether a particular candidate could be the right choice for you. Your attorney can help alert you to possible red flags, serve as an objective advisor, and draft the surrogacy contract once you have made your decision.
Name _______________________________________________________________________ Address _____________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Home telephone number _________________________________________________________ Work telephone number _________________________________________________________ E-mail address _________________________________________________________________ Age ________________ Education ____________________________________________________________________ Occupation ___________________________________________________________________ Employer ____________________________________________________________________ Marital Status _________________________________________________________________ If married, does your husband support your decision to become a surrogate? ________________ ______________________________________________________________________________ Height ________________________ Weight ________________________ List all medications currently taken _________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ List all surgeries and hospitalizations in last 10 years __________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ List all known health problems ____________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Do you suffer from mental illness? _________________________________________________ ______________________________________________________________________________ Do you have any sexually transmitted diseases? ______________________________________ ______________________________________________________________________________ Have you ever been tested for AIDS and/or HIV? __________ Results ___________________ Do you consume alcohol? _____ Quantity __________________________________________ Do you smoke? _____ Quantity __________________________________________________ Do you now or have you ever used illegal drugs? _____________________________________ _____________________________________________________________________________ List all known health problems of your parents and siblings ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Do you have children? _____ List ages ____________________ ______________________________________________________________________________ List all health concerns relating to your children ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Did you have normal pregnancies? _____ If not, explain ______________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Did you suffer from post-partum depression? ______________________________________________________________________________ ______________________________________________________________________________ What do you expect will be the impact on your children of your surrogacy? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Why do you want to be a surrogate? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Will you allow the prospective parents to be involved during the pregnancy? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Will you allow the prospective parents to be present at the delivery? ______________________________________________________________________________ Are you willing to undergo an extensive physical examination and psychological assessment before entering into the surrogacy arrangement? ______________________________________________________________________________ Do you have health insurance? ____________________________________________________ Are you willing to execute a surrogacy contract that dictates certain behaviors in which you must engage or from which you must refrain during the pregnancy? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Are you willing to relinquish all claims to the child that is born as a result of the surrogacy arrangement? ______________________________________________________________________________ |
FAQs
- Does my insurance cover infertility treatments?
- What are assisted reproductive technologies?
- What is surrogacy?
- Can children be "conceived" after a parent dies?
- Who owns the embryos produced in the process of in vitro fertilization?
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