Sample Gestational Surrogate Profile

sample of GS

SURROGATE QUESTIONNAIRE

PERSONAL INFORMATION:

First Name ONLY or Nickname: Judith
Date Of Birth: 11/26/1988
Height: 5’7
Weight: 144
Body Frame: Sm Med Lg

Have you ever been pregnant, successfully carried a child to term, and given birth? Yes

How many of your own children do you have (names and age(s): 2
Avory, 5 and Harper, 3

  • Do your children live with you? Yes No If not, please explain.
  • Do you want to have any more children of your own? No
  • Do your children all have the same genetic father? Yes If not, please explain. What is your relationship like with any/all of your children’s fathers?
  • Are you currently in a monogamous relationship? Yes
  • How many sexual partners have you had in the past 6 months? 1
  • Are you currently sexually active? Yes
  • Current Marital/Relationship Status: Married
  • If married or otherwise in a long-term relationship, how long have you been together? 6 years
  • First name ONLY of spouse or significant other: Jason
  • How does your spouse or significant other feel about you being a gestational surrogate? He is very supportive. He knows how much I love being pregnant and thinks surrogacy is such a wonderful thing.
  • Briefly describe your spouse or significant other: Jason is such a great person. He has made so many sacrifices for our family and I am so thankful to have him.
  • How did you meet? My husband and I met through our friends. My best friend was in a relationship with one of Jason’s good friends, and they introduced us. We have been together since.
  • Have you been married in the past? No Divorced? Separated?
  • Does your current partner smoke? No
  • What is your racial background: Caucasian
  • Your Ethnic Origin/Ancestry: (e.g.: German, Chinese, Native American, French-Italian, etc): Irish, Scottish, German
  • Highest Level of education: College
  • Please list any language(s) you speak besides English:
  • What is your current religious affiliation?Christian
  • Do you consider yourself to be religious or spiritual? Yes
  • How important is your religion to you? It is very important
  • How important is the religion of your Intended Parents?
  • If important, please describe why: The religion of my intended parents is not a big issue for me, because I could never tell someone that I couldn’t help them just because of their beliefs.
  • How often are you exposed to strong, prolonged heat sources such as saunas, hot tubs, steam rooms? Never
  • If regularly exposed to strong heat, please explain:
  • Do you smoke? If yes, how many cigarettes per day? (Please note: you will be tested for nicotine) No
  • Do you drink alcohol? Occasionally If yes, frequency and type? Once in a blue moon I will have a glass of wine. Not even once a month.
  • What was your childhood like? I grew up as the youngest of my family, with two older twin sisters, and an older brother. Being the youngest had its ups and downs, but I wouldn’t change anything.
  • What was your relationship like with your parents while you were growing up? My parents separated before I was born, so I was back and forth between them a lot. They were both loving parents who tried their best to give me the best life possible. You always think that your parents know nothing until you become a parent yourself!
  • What is your relationship like with your parents now? My mother and I speak daily. I don’t see my father as often, but they are both very involved in my and my children’s lives.
  • How were you disciplined as a child? I don’t remember my parents having to discipline me that often, but when they did I usually had to do extra chores, or privileges were taken away.
  • Have you ever had any experience with physical, sexual or psychological abuse? No
  • Have you or anyone in your household ever been arrested and/or convicted of a crime/felony? If yes, please give dates, explain: (please note that it is standard practice for us to do background checks on all of our surrogates) No
  • Do you follow a particular food diet or have any special dietary habits? If yes, specify: I drink mostly water, and try to eat as healthy as I can.
  • List the forms and frequency of regular exercise: I try to exercise daily, whether it is walking, or doing an exercise video in my living room.
  • Do you sleep well? Yes No
  • How many hours? I always try to get at least 8 hours of sleep.

MEDICAL INFORMATION:

  • Blood type: A
  • RH Factor: positive
  • Do you currently have any allergies? No If so, please specify and explain your reaction:
  • Do you use prescription drugs? None other than contraceptive pills. If yes, which ones and for what reasons? (Please note: your medical evaluation will include a drug screen) Loestrin
  • Do you use non-prescription drugs? If yes, which ones and for what reasons? (Please note: your medical evaluation will include a drug screen) Tylenol/Advil, and vitamins.
  • Do you use any recreational drugs? Have you used any in the past? (Marijuana, cocaine, ecstasy, Valium, etc) (Please note: your medical evaluation will include a full drug screen) No
  • In the past 5 years, have you had sexual contact with anyone in high-risk groups for AIDS? These include intravenous drug users, recipients of blood products, transfusions, immigrants from developing countries, and sexually active persons with multiple partners? If yes (in contact with risk of AIDS), explain: No
  • Are you at risk for AIDS? No
  • 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 AIDS? No
  • Do you currently have any medical problems or conditions?
  • If yes (medical problems), please explain: I have ADHD, but do not take medication for it because of the side effects.
  • When did you have the last annual physical or any other physical test (what kind of test?) done? What was the result? September 2011. Medical screening for surrogacy.
  • Have you ever had surgery? If yes, please list the year and explain reasons and result of surgery: No
  • Have you ever been advised to have any medical test or surgery but did not follow such advice? If yes (advised for test or surgery), please explain: No
  • Have you ever had surgery performed or been hospitalized overnight for any reason within the past 5 years? If yes, please provide a brief explanation of the cause, provide dates and name of facility/physician. No
  • Have you ever taken medication for psychological problems – like antidepressants? If yes, please list condition and any medications taken for treatment and dates: Yes, Zoloft, and Paxil for Post Partum Depression in 2007.

AGENCY NOTE: Like many women, Judith had PPD with her first pregnancy and it was a mild case. She has not had it with any other pregnancies. She spoke with psychologist about it prior to her last surrogacy with us. She did not have any issues with it with her surrogacy pregnancy

  • Have you ever been in counseling or psychotherapy? If yes (counseling or psychotherapy), please list dates and diagnosis or reason: No
  • Have you ever attempted suicide or contemplated it? No
  • What medications/recreational or otherwise are you currently using or have used in the past? (Please note: you will be and can be tested at any time for drugs & alcohol) None
  • Have you ever been advised to limit your use of alcohol or any drugs? If yes (limit alcohol or drugs), please explain: No
  • Do you have a history of eating disorders? If yes (eating disorders), please explain: No
  • Have you ever had a mental or nervous disorder including depression, anxiety, etc.? Please explain the circumstances and what treatment, if any, was given? Brief Post Partum Depression after my first child was born. It was not repeated with any of my other pregnancies.
  • Have you ever had any problems with alcoholism or drug abuse? Please explain the circumstances and what treatment, if any, was given? No
  • Have any of your immediate family (parents, siblings, spouse, children) ever had a mental or nervous disorder including depression, anxiety, schizophrenia, etc.? Please explain the circumstances and what treatment, if any, was given? No
  • Have you been tattooed or had a non-sterile skin piercing procedure in the last 12 months? If yes, please describe: No
  • Have you ever been refused as a blood donor? No If yes, please explain:
  • Indicate whether you have ever had any of the following diseases:

    AIDS/HIV No
    Chlamydia No
    Diabetes No
    Thyroid Disorder No
    Leukemia No
    Anemia No
    Cancer No
    Cyst No
    Tumor No
    Heart Condition No
    High Blood Pressure No
    Chest pain No
    High Cholesterol No
    Gonorrhea No
    Hepatitis B No
    Hepatitis C No
    Herpes No
    Liver Disease No
    Tuberculosis No
    Diabetes No
    Hypoglycemia No
    Psychiatric Disorders No
    CMV No
    Reproductive Disorders No
    Breast disorders No
    Viral Hepatitis A, B, D No

  • Please check any of the following you’ve experienced with any of your pregnancies:

    Still Birth No
    Caesarian Section No
    Physician Ordered Bed Rest No
    Toxemia No
    Ectopic Pregnancy No
    Placentia Previa No
    Gestational Diabetes No
    Premature Birth No
    High blood pressure No
    Endometriosis No
    Infected Tubes or Ovaries No
    Other No

REPRODUCTIVE HISTORY:

AGENCY NOTE: To be considered as a surrogate gestational carrier, you must have carried to term and given birth to at least one child.

Please give the following info for all children born:

Delivery Date Birth Weight Length of Pregnancy Single/Multiple Vaginal/C-Section
1 7/31/07 8lbs 3 ¾ oz 40 wks Single Vaginal
2 7/17/09 7 lbs 8 oz 37 wks Single Vaginal
3 7/27/12 8 lbs 12 oz 40 wks Single Vaginal

you must have carried to term and given birth to at least one child.

  • What were your pregnancies like? All of them were wonderful. Very quick vaginal deliveries. Any complications? No
  • How long were you in the hospital after your delivery(s)? 2 days, 5 days, 2 days
  • Number of pregnancies: 3
  • Number of live births: 3
  • Number of miscarriages: 0
  • Miscarriage Date(s):
  • What did the doctor tell you the reason for the miscarriage was?
  • Number of abortions: 0
  • Abortion Date(s):
  • Have you ever had an infection (fever, pain, bleeding) following childbirth, miscarriage, or abortion?
  • If yes (had an infection), please explain: No
  • When did you first get your menstrual period – at what age?12 How often do you get it? every 28 days Are you regular? Yes Do you or did you ever have cramping, heavy bleeding, etc? If yes, please explain. Heavy bleeding and cramping. Have you ever taken medications for your periods? No
  • Have you ever been seen by a doctor for infertility treatment? If yes (infertility treatment), explain: No
  • Have you ever been told of any gynecological problems (endometriosis, ovarian cysts, fibroids, abnormal pap smears, etc.?)? If yes, please explain: No
  • Have you ever placed a child for adoption? No
  • If so (placed a child for adoption), please describe your experience:
  • Did your mother take DES while she was pregnant with you? No
  • Have you ever had a baby with any sort of birth defect or genetic abnormality? If yes, please explain:
  • Have you used contraceptives? Yes
  • Which contraceptive method do you use currently? Loestrin – Pill
  • How long after stopping contraceptives did it take to get pregnant? 1-2 months
  • Are you currently breastfeeding? If so, for how long have you been breastfeeding? When do you anticipate stopping? No

EMPLOYMENT

  • Are you currently working? Yes
  • What type of company/industry do you work for? Small printing business
  • How many hours a week do you work? 35-40 hrs.
  • What specifically is your occupation/position? Cashier
  • What are your duties? Handle transactions, and take orders for custom prints.
  • How long have you worked for your current employer? This is my second year.
  • What is your approximate weekly income (pay stubs will be necessary to verify when matched with Intended Parents)? $350 – $400

AGENCY NOTE: Judith cannot get pay stubs to verify income so she is not asking for lost wages for her own job.

  • Do you get any commission as part of your income? If so, what is the amount (verification will need to be supplied for reimbursement.) No
  • Spouse or Significant Other’s occupation: Contractor, Pt time Vendor.
  • Spouse or Significant Other’s approximate weekly income? (only necessary if you anticipate that s/he may need lost wage reimbursement — pay stubs will be necessary to verify when matched with Intended Parents)? $500
  • Do you own and drive a car? Yes
  • Do you have automobile insurance? Yes
  • Do you have a valid driver’s license? Yes

INTERESTS

  • What is your favorite type of music? Contemporary
  • Who is your favorite singer? Francesca Battistelli
  • What is your favorite movie? To save a life
  • What is your favorite book? Suzanne’s Diary for Nicholas
  • Author? James Patterson
  • What are your favorite magazines? Cooking, and hair magazines.
  • What is your favorite TV show? Once Upon a Time
  • What are your favorite foods? Asian, and comfort foods.
  • What is your favorite restaurant? Chili’s
  • What is your favorite color? Teal/Turquoise
  • What is your favorite flower? Lilies
  • Do you have any hobbies? I love arts and crafts. I sew, crochet, paint, etc.
  • Do you collect anything special?
  • What type of jewelry do you like to wear? I don’t wear a lot of jewelry Favorite stones? Gold or silver? Silver
  • Where would you most like to travel and why? I would like to see Hawaii. My sister lived there, and I was never able to visit.
  • What is your favorite thing to do? I love being able to make people feel good about themselves. I went to cosmetology school and love doing hair and makeup.
  • What do you like doing most with your family? Watching movies, going to the park, fishing.
  • Does your husband/partner collect anything special? Tools.
  • What are you/and partner’s favorite sports teams? VA Tech
  • What are the ages of your children and do they collect anything or enjoy anything in particular? Avory is 5, and she loves just about anything girly. Harper is 3 and he loves Power Rangers.
  • What is your ultimate goal or ambition in life? To have a nice job, and to be able to give my children the best life they can have.
  • What do you think is the biggest stress in your life at present? My daughter is having a hard time adjusting to kindergarten. I really hate seeing her struggle, but we have been working very hard.
  • What problems did you have as a child? I don’t remember having any major problems.
  • How would you describe yourself? Please include a description of your personality and temperament (quite, upbeat, artistic, etc.) : I am artistic. I can be quiet and upbeat at times. I love to have fun with whatever I am doing.
  • Describe your philosophy of life: We are not guaranteed another second of life. I want to live everyday as if it were my last. Here is one of my favorite quotes:

    Our deepest fear is not that we are inadequate. Our deepest fear is that we are powerful beyond measure. It is our light, not our darkness that most frightens us. We ask ourselves, ‘Who am I to be brilliant, gorgeous, talented, fabulous?’ Actually, who are you not to be? You are a child of God. Your playing small does not serve the world. There is nothing enlightened about shrinking so that other people won’t feel insecure around you. We are all meant to shine, as children do. We were born to make manifest the glory of God that is within us. It’s not just in some of us; it’s in everyone. And as we let our own light shine, we unconsciously give others permission to do the same. As we’re liberated from our own fear, our presence automatically liberates others.

  • Are their any specific goals you are working towards? (Personal or professional) If so, please let us know: I just want to be the best mother I can be.
  • What makes you angry? It takes a lot to make me angry.
  • What makes you feel happy? I love being around my family and spending quality time together.
  • Have you ever been depressed? I don’t get depressed out of the blue. When do you get down (or depressed)?
  • Why and for how long?
  • Describe your sense of humor: I like to joke around and play silly pranks on friends and family.

SURROGACY

  • How did you become interested in becoming a gestational surrogate? I have an infertile friend, and I would have loved to have been able to help her. That is what actually put the idea in my head. I never knew how rewarding it could actually be, until I went through it the first time.
  • What does being a surrogate mother mean to you? It means, being able to help a family who wouldn’t be able to have children if it weren’t for people who are willing. Being able to be a surrogate is something that I hold very close to my heart.
  • 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 5
    I need the income 1
    Having a child for an infertile couple would bring me great happiness 5

  • How do you view other people who have suffered with infertility or experienced difficulty becoming pregnant or having a family of their own? I see them as people who have been through a lot of heartache to get something that comes so easily to many of us.
  • Being a surrogate involves an extensive time commitment, which typically includes fertility medication, extensive testing, pregnancy and childbirth, and possible surgical procedures. Will this present a problem? No
  • Have you ever been a surrogate before? Yes If so, how many times? 1
  • If so, who was the doctor or doctors each time? Dr Sahakian in Los Angeles, CA
  • How many months between stopping birth control and conception? Less than a month.
  • How many attempts or transfers were there until you became pregnant? 1
  • What were the circumstances? Donor egg or IM’s eggs? Donor How old was IM? 55
  • Were there any failed cycles (negative betas or chemical pgs)? No (If yes, please explain circumstances for each situation as best you can, include fertility clinic, RE name, etc)
  • Were there any miscarriages? No
  • Was there a pregnancy? Yes
  • Was there a live birth? Yes
  • How long did you carry for? 40 weeks and 1 day
  • Have you ever had a c-section? If yes, please explain why: No
  • If you have been a surrogate before please describe the overall experience. What things did you like about it and what things would you like to avoid in your next surrogacy? It was wonderful. It was definitely one of the best things I have ever done. The only thing I would really like to change is that I would want more in person contact with my IPs.
  • AGENCY NOTE: Judith is aware that sometimes this can’t happen because of logistical reasons and she is ok with that.
  • Do you have any personal concerns about becoming a surrogate? No
  • What difficulties do you anticipate in becoming a surrogate? I hope there are none.
  • How many transfer attempts would you feel comfortable with in order to become pregnant? 4
  • Are you willing to reduce the amount of caffeine and soda you consume during the pregnancy (coffee, tea, etc.)? Yes
  • Are you open to making other lifestyle changes at the request of the Intended Parents? Yes
  • Are your partner and close family (parents, children, siblings) supportive of your decision to become a surrogate? Yes
  • Please describe your support system. For instance, who would help you if you were on doctor-ordered bed rest for a period of time? My husband, and sister in law.
  • Would you require day care/baby sitting to attend any appointments associated with surrogacy related appointments? Some
  • Who helps you with child care (when needed)? How much do you pay them per hour, if at all? My sister and sister in law. $10/hr
  • How close are you to the nearest hospital? What is the name of it and the town/city it’s located in? 5-10 minutes. Bluefield Regional Medical Center. Bluefield, WV

    AGENCY NOTE: This is where Judith delivered her last surrogate baby.

  • Are you planning or thinking of moving in the upcoming year? If so, why and where are you thinking of moving to? No

COMPATABILITY

  • Describe ideal intended parents for whom you would like to be a surrogate:
  • What would you especially like the child/children to know about you? That I wanted to give their parents the best gift I could possibly give.
  • What do you think of communication with IPs using email? Would you be able to check your email regularly? This is fine with me. Yes
  • Would you like to communicate through phone calls? Yes If so, how often? I am open
  • How much involvement from the IP’s do you want during the pregnancy? I want them to be involved as much as they can.
  • Would you be willing to have the Intended Parents at transfer(s) and doctor appointments? Yes, I would love that.
  • How do you feel about the Intended Parents being in the delivery room with you? Seeing their child being born is something that I feel every parent should be able to witness. I would absolutely welcome them into the delivery room.
  • Is there anyone else you would like to have in the delivery room? My husband.
  • How do you feel about pumping breast milk for your surro-baby? (Some IPs would like this – and if they do and you are okay with it, you will get compensated each $250/wk + supplies and shipping costs) I am open.
  • Some Intended Parents do not live near their surrogates. How do you feel about having Intended Parents that cannot attend doctor appointments and see you on a regular basis? I really would like as much contact as possible, even if that is only a few appointments.

AGENCY NOTE: Again, Judith understands that logistically sometimes IPs can’t make it to appointments but she hopes that the IPs will want to be there for as many as possible.

  • Would you be willing to work with same sex couples? I would rather work with a traditional couple at this time.
  • Would you be willing to work with single Intended Parents? No
  • Would you be willing to work with Intended Parents who already have a child/children? Yes
  • Would you be willing to work with Intended Parents who choose to do sex selection (through PGD – done prior to embryo transfer)? Dependent on the situation
  • Would you be willing to give birth in another state? Depending on the situation
  • Would you be willing to have embryo transfer in another state? Yes
  • Would you need to bring your children when you need to travel for surrogacy? Most likely no.
  • When are you ready to begin? Now.
  • What kind of relationship would you like with the Intended Parents after the birth of the child(ren)? This would probably depend on the type of relationship we build during the pregnancy, but ideally I would like to keep in touch.
  • What kind of relationship would you like with your surro-children? I would love for them to know who I am.
  • How do you feel about the possibility of carrying more than one baby as a surrogate gestational carrier? I realize this is a possibility, but would not want to carry more than two babies, unless there were special circumstances.
  • If recommended by a physician, would you be willing to undergo CVS, amniocentesis or other diagnostic testing to determine the presence of birth defects? Yes
  • If there were a serious problem with the fetus and the intended parents wanted to terminate the pregnancy, would you be willing to terminate the pregnancy?I am fine with the IPs deciding if they are faced with having to make this difficult decision.
  • If you were pregnant with more than two fetuses would you be willing to undergo selective reduction in order to increase the chances of survival and health for the remaining fetuses? Yes. I would not want to transfer more than two, but if we still ended up with more than two babies I would be open.
  • Are there any specific conditions in which you would not terminate a pregnancy? If yes (conditions not to terminate), please explain: I am aware that termination is not something IPs take lightly and I am willing to respect their decision.
  • Would you be willing to carry triplets? If precautions were taken to lessen the chance of triplets, and we still ended up with them I would be willing to carry all three, if that is what is agreed upon by all parties.
  • Do you think your OB/GYN would be supportive of you helping aspiring parents have a baby? Yes, he is very supportive.
  • As a surrogate, what reassurance can you give that you will not change your mind about relinquishing the child? I have been a surrogate before, and did not have any maternal connection or bond with the child I carried, even though I loved the family.
  • My wish for the child/children I carry and deliver is: That they follow their dreams and be whoever they want to be.
  • Is there anything you would like to add or say to potential Intended Parents that was not included in this questionnaire? Please use the space below and other side of this page if needed. I can only imagine what you have gone through to get to this point. Please know that in every answer I gave I was as honest and real as I could possibly be, because I know that this must be a difficult decision for you as parents to be. Even if you don’t choose me to be your surrogate, I still want to wish you the best of luck in your journey to parenthood. Best Wishes, Judith