II. Family Characteristics

How many brothers do you have?
How many sisters do you have?

Is there a history of infertility in your family? [ ] YES [ X ] NO [ ] UNSURE

III. Education

Completed high school: Yes
Currently in college, pursuing degree in: Yes
Completed college, degree in:
Currently pursuing advanced degree in: ______________________________________________
Completed advanced degree in: ______________________________________________________

IV. Hobbies

Traveling

V. SOCIAL AND PERSONAL HISTORY

Do you smoke cigarettes?: [ ] YES [ X ] NO
If YES, How much? ____________________________
Have you had and/or been treated for a substance/alcohol abuse addiction problem?
[ ] YES [ X ] NO
Do you have any legal cases pending against you? [ ] YES [ X ] NO
If yes, explain:___________________________________________________________________
Have you ever filed for bankruptcy? [ ] YES [ X ] NO
Have you ever been convicted of a crime, or been in prison greater than 72 hours?
[ ] YES [ X ] NO
If yes, explain:____________________________________________________________________
_________________________________________________________________________________
Do you have a driver’s license? [ ] YES [ X ] NO
Do you have a car? [ ] YES [ X ] NO

VI. Obstetrical History

Number of pregnancies: 1
Mode of delivery
#of vaginal deliveries: 1
# of Caesarean deliveries:
# of miscarriages:
#of abortions:
# of ectopic pregnancies:
Number of children: 1
# Girls: 1
# Boys:
Their ages: 8 Years old
Have you ever been surrogate mother before? []  YES [X]  NO

VII. Medical Questions

Please indicate with a check mark (and date) if you had any of the following:

DATE:
If yes, please specify:

VIII. Other Medical Questions

Do you drink alcoholic beverages? [   ]  YES     [ x ]    NO
If so, which kinds?       Beer ______  Wine ______   Liquor ______
Do you smoke cigarettes? [   ]  YES     [ x ]    NO