Initial GS Screening Questionnaire, gift card for qualified candidates Name Email Phone Number City State you currently reside in Age Height Current Weight lbs. Weight you were at when you last got pregnant lbs. Number of children Current age(s) of child(ren) Length of time carried in weeks for each pregnancy How long did it take to conceive? Number of C-sections, please state with which child? Please list any complications with any of your pregnancies (high blood pressure, preeclampsia, placenta previa, diabetes, etc.) When was your last pap smear? Was it normal? Have you ever had an abnormal pap smear? If so, when and what was the result? Current method of birth control Have you spoke to your OB about being a surrogate? Will s/he write you a letter to confirm you are ready and able to be a GS? Have you had any tattoos or piercings in the last year? YesNo Single or married? SingleMarried Please describe your support system Will you be willing to travel out of state for an initial medical evaluation and then embryo transfer? Have you ever been a Surrogate before? NoYes If so, how many times? Why do you want to be Gestational Surrogate? Are you open to selective reduction (in the case of triplets or more) and termination for chromosomal abnormalities? (If you are unsure please say “not sure”.) Do you have insurance that will cover a surrogacy pregnancy? (If you are unsure please say “not sure”.) Let us know how you found us; Facebook, Google Ad, Craigslist, your own search
