SM 145

Surrogate Mother’s Name: SM 145

I. PHYSICAL CHARACTERISTICS

Date of Birth: 08/02/1995
Nationality: Georgian
Blood type/RH A+
Height: 166
Weight: 56
Eye color: Blue
Hair Natural color: Blond

II. Family Characteristics

How many brothers do you have?
How many sisters do you have? 2

AGE EYE COLOR HAIR COLOR HEIGHT BODY TYPE BLOOD TYPE/RH ETHNIC ORIGIN
MOTHER 39 Blue Blond 169 Normal Georgian
FATHER 45 Blue Light Brown 182 Normal Georgian
BROTHERS
1.
2.
3.
SISTERS
1. 20 Blue Blond 169 Normal Georgian
2. 18 Brown Brown 166 Normal Georgian
3.
GRAND FATHERS (MATERNAL) 68 Brown Black 180 Normal Georgian
GRAND MOTHERS (MATERNAL) 66 Blue Blond 169 Normal Georgian
GRAND FATHERS (PATERNAL) 72 Blue Blond 187 Normal Georgian
GRAND MOTHERS (PATERNAL) 70 Blue Blond 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: Faculty of Medicine
Completed college, degree in:
Currently pursuing advanced degree in: ______________________________________________
Completed advanced degree in: ______________________________________________________

IV. Hobbies

Walking, 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:
# Boys: 1
Their ages: 3 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)
Grandmother (paternal)
Grandfather (maternal)
Grandmother (maternal)
father
mother
Brothers
1.
2.
3.
Sisters:
1.
2.
3.
Categories:

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