Surrogate Mother’s Name: SM 23
I. PHYSICAL CHARACTERISTICS
| Date of Birth: | 16/10/1986 |
| Nationality: | Georgian |
| Blood type/RH | A+ |
| Height: | 165 |
| Weight: | 58 |
| Eye color: | Blue |
| Hair Natural color: | Brown |
II. Family Characteristics
How many brothers do you have?
How many sisters do you have?
| AGE | EYE COLOR | HAIR COLOR | HEIGHT | BODY TYPE | BLOOD TYPE/RH | ETHNIC ORIGIN | |
| MOTHER | 60 | Blue | Brown | 165 | Normal | O+ | Georgian |
| FATHER | Dead | Blue | Blond | 180 | Normal | A+ | Georgian |
| BROTHERS | |||||||
| 1. | |||||||
| 2. | |||||||
| 3. | |||||||
| SISTERS | |||||||
| 1. | |||||||
| 2. | |||||||
| 3. | |||||||
| GRAND FATHERS (MATERNAL) | Dead | Georgian | |||||
| GRAND MOTHERS (MATERNAL) | Dead | Georgian | |||||
| GRAND FATHERS (PATERNAL) | Dead | Georgian | |||||
| GRAND MOTHERS (PATERNAL) | Dead | 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
Music
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: 3
Mode of delivery
#of vaginal deliveries: 2
# of Caesarean deliveries:
# of miscarriages:
#of abortions: 1
# of ectopic pregnancies:
Number of children: 1
# Girls: 1
# Boys:
Their ages: 7 Years old
Have you ever been surrogate mother before? [X] YES [] NO
If yes, how many times? 1
When?
First: 2016
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 | 80 | Age |
| Grandmother (paternal) | Dead | 82 | Age |
| Grandfather (maternal) | Dead | 78 | Age |
| Grandmother (maternal) | Dead | 80 | Age |
| father | |||
| mother | |||
| Brothers 1. 2. 3. |
|||
| Sisters: 1. 2. 3. |
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