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Date
Email Address
Full Name
Street Address
City
State
Zip
Date of Birth
Home Phone
Cell Phone
Work Phone
Height
Weight
Specifically, how did you hear about us?
Have you been a surrogate before?	Yes No
When? (Month/Year)
Do you smoke?	Yes No
Have you smoked in the past?	Yes No
If so, how long ago did you smoke and how long ago did you quit?
Ever been arrested?	Yes No
If yes, explain:
Were you convicted?	Yes No
Have you had a body piercng or tattoo within the past year?	Yes No
If yes, describe which one and give a date of most recent:
Are you drug and disease free?	Yes No
Have you experimented with drugs in the past?	Yes No
If so, what, how many times, and how long since your last use?
Are you married?	Yes No
Husband or partner supportive?	Yes No
How many children do you have?
Ages
Occupation
Employer
Do you have health insurance?	Yes No
Provider
Does your policy include maternity benefits?	Yes No
Will your policy cover your surrogate pregnancy and delivery?	Yes No
Education
Have you taken prescription medication in the past year?	Yes No
If yes, what did you take, how long ago, and what were you being treated for?
What type of birth control do you use?
Have you ever taken antidepressants?	Yes No
If yes, when, what and how long?
Did you stop under a physicians cares?
Date of last pap smear (month/year):
Date of last HIV test?