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What is your partner/spouse's legal name?
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Who is your partner/spouse's employer?
What is his/her title/position?
Please list the first name, age, and relationship to you of everyone who you live with, including children
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Have you applied to any other agencies?
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If yes, please describe.
How did you hear about us?
Who is your present employer?
Are you required to do heavy lifting at work?
Yes
No
If yes, how many Ibs?
Do you have medical insurance?
Yes
No
What is the name of your health insurance carrier?
How many days per week do you use tobacco in any form?
How many days per week does your partner/spouse or roommate smoke per week?
How many days per week do you drink alcoholic beverages?
When is the last time you had marijuana?
When is the last time you have used recreational or illicit drugs?
(cocaine, LSD, heroin, barbiturates, narcotics, opiates, amphetamines, hallucinogens, tranquilizers, PCP, steroids for non-medical reasons, or etc.)
Have you ever been diagnosed with herpes?
Yes
No
Have you ever been diagnosed with gonorrhea?
Yes
No
Have you ever been diagnosed with chlamydia?
Yes
No
Have you ever been diagnosed with syphilis?
Yes
No
Have you ever been diagnosed with HPV?
Yes
No
Have you ever been diagnosed with genital warts?
Yes
No
Has your partner / spouse ever been diagnosed with gonorrhea, chlamydia, syphilis, HPV, genital warts or herpes?
Yes
No
Please list any surgeries you have had.
(Surgery, Year, Reason for Surgery, & Outcome)
Please list any medications you are currently taking.
Please list any CURRENT medical conditions.
Please list any PAST medical conditions.
Do you have or have had asthma?
Yes
No
Do you have, or have you ever had, depression?
Yes
No
Do you have or have had diabetes?
Yes
No
Do you have or have had eating disorders?
Yes
No
Do you have or have had heart problems?
Yes
No
Do you have or have had high blood pressure?
Yes
No
Do you have or have had migraine headaches?
Yes
No
How many pregnancies have you had?
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How many miscarriages have you had?
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How many abortions have you had?
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How many living children do you have?
How many children with physical birth defects have you had?
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How many children with mental health defects have you had?
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Please provide the following information regarding ALL pregnancies including abortions and miscarriages.
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Please describe any problems with any pregnancy, delivery or birth. Please include any birth defects or issues associated with any children.
What is the date of your last delivery?
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What kind of birth control do you use?
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If you have an IUD, do you agree to schedule an appointment as soon as possible to remove it?
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Yes
No
N/A
Do you have a menstrual cycle every month?
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Yes
No
How many days are between your periods?
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What is the date of your last menstrual cycle?
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What was the date of your last Pap Smear?
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What was the result of your last Pap Smear?
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Have you had a Hep B vaccination?
Yes
No
What was the result of your Hep B?
What is your Blood Type?
What is your highest level of completed education?
High School
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PhD
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Have you ever placed a child up for adoption? or have you ever given custodial rights to someone else? If so who?
Have you ever been sexually assaulted?
Yes
No
Have you ever had psychological counseling?
Yes
No
Have you ever been convicted of a crime? If yes, please explain (including year)
Has your partner ever been convicted of a crime? If yes, please explain (including year)
Have you ever been arrested, including a DUI arrest? If yes, please explain (including year)
Do you currently have any legal cases or claims pending?
Yes
No
Do you understand you will need to ultimately submit to us a copy of your obstetric records from your prior pregnancies and deliveries, your most recent physical exam results from your primary care provider, along with a Pap smear results and any other tests that were completed?
Yes
No
With the understanding that expenses are paid by the recipient(s), would you be willing to travel by car to a neighboring city for appointments?
Yes
No
With the understanding that expenses are paid by the recipient(s), would you be willing to travel by plane to another city for appointments?
Yes
No
From which family types would you be willing to carry a child?
Would you be willing to carry a child for a recipient(s) who are over 50 years old? (optional)
Yes
No
Would you be willing to carry a child whereby the recipients used donor egg or donor sperm?
Yes
No
Would you be willing to carry a child for a recipient(s) who will raise this child in a religion different from your own?
Yes
No
Would you be willing to undergo genetic testing?
Yes
No
Would you be willing to terminate the pregnancy if there should be a significant qualify of life issue?
*
Yes
No
Based on the preference of the intended parent/s beliefs and in the best interest of the child, would you be willing to terminate the pregnancy?
*
Yes
No
Are you willing to carry for an Intended Parent/s who have Hep B?
Yes
No
Would you be willing to carry for an Intended Parent(s) that is HIV Positive?
*
Yes
No
You will be required to take IVF medications. Some meds require using injectable needles. Do you agree to take ALL medications required?
*
Yes
No
Are you willing to transfer more than 1 embryo?
Yes
No
Are you willing to carry twins or more, if an embryo should split?
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Yes
No
We prefer to do a total of 3 transfers attempts if unsuccessful. Are you okay with this?
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Yes
No
If you happen to have triplets or more, would you be willing to have a "selective reduction" (Terminate 1 or more specific fetuses to achieve twins)? If yes, please specify what selective reduction options you are willing to agree to.
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Who are you willing to have on Ob/Gyn appointments?
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Who are you willing to have on Fertility Center appointments?
*