Surrogate Mother’s Name: SM 95
I. PHYSICAL CHARACTERISTICS
Date of Birth: | 26/12/1985 |
Nationality: | Georgian |
Blood type/RH | O+ |
Height: | 175 |
Weight: | 65 |
Eye color: | Brown |
Hair Natural color: | Brown |
Date of Birth: | 26/12/1985 |
Nationality: | Georgian |
Blood type/RH | O+ |
Height: | 175 |
Weight: | 65 |
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 | 55 | Brown | Brown | 167 | Normal | Georgian | |
FATHER | 60 | Brown | Brown | 190 | Thin | Georgian | |
BROTHERS | |||||||
1. | Dead | Brown | Brown | 180 | Normal | Georgian | |
2. | |||||||
3. | |||||||
SISTERS | 34 | Brown | Brown | 170 | Normal | Georgian | |
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 | Blond | 185 | Normal | Georgian | |
GRAND MOTHERS (PATERNAL) | Dead | Brown | Black | 169 | Normal | Georgian |
Is there a history of infertility in your family? [ ] YES [ X ] NO [ ] UNSURE
Completed high school: Yes
Currently in college, pursuing degree in: Yes
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: 2
Mode of delivery
#of vaginal deliveries: 1
# of Caesarean deliveries: 1
# of miscarriages:
#of abortions:
# of ectopic pregnancies:
Number of children: 2
# Girls:
# Boys: 2
Their ages: 2 and 4 Year old
Have you ever been surrogate mother before? [] YES [X] NO
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 | 70 | Age |
Grandmother (paternal) | Dead | 75 | Age |
Grandfather (maternal) | Dead | 65 | Age |
Grandmother (maternal) | Dead | 78 | Age |
father | Dead | 60 | Age |
mother | |||
Brothers 1. 2. 3. |
Dead | 29 | Car Accident |
Sisters: 1. 2. 3. |