Surrogate Mother’s Name: SM 76
I. PHYSICAL CHARACTERISTICS
Date of Birth: | 14/03/1982 |
Nationality: | Georgian |
Blood type/RH | O+ |
Height: | 158 |
Weight: | 58 |
Eye color: | Brown |
Hair Natural color: | Brown |
Date of Birth: | 14/03/1982 |
Nationality: | Georgian |
Blood type/RH | O+ |
Height: | 158 |
Weight: | 58 |
Eye color: | Brown |
Hair Natural color: | Brown |
How many brothers do you have? 1
How many sisters do you have? 1
AGE | EYE COLOR | HAIR COLOR | HEIGHT | BODY TYPE | BLOOD TYPE/RH | ETHNIC ORIGIN | |
MOTHER | Dead | Brown | Brown | 165 | Normal | Georgian | |
FATHER | 67 | Brown | Brown | 165 | Normal | Georgian | |
BROTHERS | |||||||
1. | 25 | Blue | Blond | 165 | Normal | Georgian | |
2. | |||||||
3. | |||||||
SISTERS | |||||||
1. | 37 | Brown | Brown | 169 | Normal | Georgian | |
2. | |||||||
3. | |||||||
GRAND FATHERS (MATERNAL) | Dead | ||||||
GRAND MOTHERS (MATERNAL) | Dead | ||||||
GRAND FATHERS (PATERNAL) | Dead | Brown | Brown | 2.00 | Normal | Georgian | |
GRAND MOTHERS (PATERNAL) | Dead |
Is there a history of infertility in your family? [ ] YES [ X ] NO [ ] UNSURE
Completed high school: Yes
Currently in college, pursuing degree in: Faculty of Psychology
Completed college, degree in:
Currently pursuing advanced degree in: ______________________________________________
Completed advanced degree in: ______________________________________________________
Reading
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
Number of pregnancies: 5
Mode of delivery
#of vaginal deliveries: 5
# of Caesarean deliveries:
# of miscarriages:
#of abortions:
# of ectopic pregnancies:
Number of children: 1
# Girls: 1
# Boys:
Their ages: 10 Years old
Have you ever been surrogate mother before? [X] YES [] NO
If yes, how many times? 4
When?
First: 2008
Second: 2012
Third: 2014
Fourth: 2015
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:
Do you drink alcoholic beverages? [ ] YES [ x ] NO
If so, which kinds? Beer ______ Wine ______ Liquor ______
Do you smoke cigarettes? [ ] YES [ x ] NO
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 | 65 | Heart |
Grandmother (paternal) | Dead | 80 | Age |
Grandfather (maternal) | Dead | 75 | Age |
Grandmother (maternal) | Dead | 78 | Age |
father | |||
mother | Dead | 40 | Cancer |
Brothers 1. 2. 3. |
|||
Sisters: 1. 2. 3. |