North Carolina Surrogate Mother and Egg Donor - Surrogate Preliminary Questionnaire

If you are interested in becoming a surrogate please fill out the preliminary form below.

First Name:
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Last Name:
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Address:
City:
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State:
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Zip Code:
Email Address:
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Age:
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Height:
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Weight:
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Ethnicity (Irish/English/Hispanic/African American/etc):
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Married
Divorced
Separated
Single
In a Committed Relationship
Why do you want to be a surrogate?
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Do you want to be a Gestational or Traditional Surrogate?
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What do your family/friends/spouse think of your decision to become a surrogate mother?
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Do you smoke? (If so how many per day)
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Does anyone in your home smoke?
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Do you drink? (if yes how often?)
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Are you currently taking any medications or did you stop taking any medications in the last two years? If yes give details:
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Have you ever given birth? (please give dates)
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How long did it take you to conceive each pregnancy?
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At what gestational age did you deliver? (for example: 38 weeks gestation)
What complications did you encounter during your previous pregnancies/deliveries? (for ex: Gestational diabetes/High blood pressure/Pre term labor/ Shoulder dyscocia during delivery/ any other complications during pregancy or delivery)
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How many c sections have you had?
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Number of miscarriages you have had?
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Number of abortions you have had?
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Number of ectopic pregnancies?
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How many children born to you are you currently raising or have raised?
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What kind of birth control are you currently using?
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Have you ever had the depo provera injection or birth control implant? If yes please state when you last used?
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Have you ever participated in mental health counseling?
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Have you ever experienced emotional/physical trauma? (If yes give details)
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Have you ever been diagnosed with an STD? (If yes give details)
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Do you have insurance that does not have an exclusion against you being a surrogate? (If yes what insurance company are you with?)
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Are you willing/able to provide medical records?
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If the child you carry for a couple is found to have a birth defect would you be willing to terminate the pregnancy if this is the wish of the Intended Parents? Please elaborate on your answer.
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If you end up pregnant with triplets or more will you agree to undergo selective reduction to ensure you carry no more than twins?
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Do you have any plans to move out of your current location anytime in the next 18 months? If yes provide details.
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Please list any health issues you have now or had previously: (for ex: Thyroid/Blood pressure/any other medical issue even if mild):
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What does your family/circle of friends think about you becoming a surrogate?
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How did you hear about us?

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