SM 136 – IVF Tours Georgia

Surrogate Mother’s Name: SM 136

I. PHYSICAL CHARACTERISTICS

Date of Birth:	05/04/1991
Nationality:	Georgian
Blood type/RH	B-
Height:	165
Weight:	79
Eye color:	Brown
Hair Natural color:	Brown

II. Family Characteristics

How many brothers do you have? 1
How many sisters do you have?

	AGE	EYE COLOR	HAIR COLOR	HEIGHT	BODY TYPE	BLOOD TYPE/RH	ETHNIC ORIGIN
MOTHER	56	Brown	Brown	167	Normal		Georgian
FATHER	61	Brown	Brown	182	Normal		Georgian
BROTHERS
1.	27	Brown	Brown	175	Normal		Georgian
2.
3.
SISTERS
1.
2.
3.
GRAND FATHERS (MATERNAL)	Dead	Brown	Brown	180	Normal		Georgian
GRAND MOTHERS (MATERNAL)	Dead	Brown	Brown	170	Normal		Georgian
GRAND FATHERS (PATERNAL)	Dead	Brown	Brown	185	Normal		Georgian
GRAND MOTHERS (PATERNAL)	Dead	Blue	Brown	169	Normal		Georgian

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:
Completed college, degree in:
Currently pursuing advanced degree in: ______________________________________________
Completed advanced degree in: ______________________________________________________

IV. Hobbies

Reading

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:
# of Caesarean deliveries: 1
# of miscarriages:
#of abortions:
# of ectopic pregnancies:
Number of children: 1
# Girls: 1
# Boys:
Their ages: 1 Year 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:

Gonorrhea	[ ] YES [ X ] NO
Kidney disease	[ ] YES [ X ] NO
Blood clots	[ ] YES [ X ] NO
Syphilis	[ ] YES [ X ] NO
AIDS/HIV	[ ] YES [ X ] NO
Liver disease	[ ] YES [ X ] NO
Phlebitis	[ ] YES [ X ] NO
Herpes	[ ] YES [ X ] NO
Diabetes	[ ] YES [ X ] NO
Hepatitis B	[ ] YES [ X ] NO
Excessive facial hair	[ ] YES [ X ] NO
Heart disease	[ ] YES [ X ] NO
Other disease	[ ] YES [ X ] NO
Depression	[ ] YES [ X ] NO
Anxiety	[ ] YES [ X ] NO
Eating Disorders	[ ] YES [ X ] NO
Manic Depression	[ ] YES [ X ] NO
Schizophrenia	[ ] YES [ X ] NO
Suicide Attempt	[ ] YES [ X ] NO
Have you ever been seen by a psychiatrist, psychologist, social worker or other mental health worker for any reason?	[ ] YES [ X ] NO

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

IX. FAMILY MEDICAL HISTORY

Are there any known genetic diseases or conditions that run in your family? [ ] YES [ x ] NO
If yes, what are they? _______________________________________________________
Has anyone in your family, including yourself and your first cousins, experienced recurring and/or
chronic physical symptoms that have not been evaluated by a physician?
(Please include those symptoms that you may not consider serious.) [ ] YES [ x ] NO
Please explain: _________________________________________________________________
____________________________________________________________________________

List below at what age your family member died and the cause of their death.
Please be as specific as possible.

Relation	Age Diagnosed	Age at the time of death	Cause of death
Grandfather (paternal)	Dead	86	Age
Grandmother (paternal)	Dead	85	Age
Grandfather (maternal)	Dead	79	Age
Grandmother (maternal)	Dead	84	Age
father
mother
Brothers 1. 2. 3.
Sisters: 1. 2. 3.

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