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Pre-Screening Form
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First name
(Required)
Last name
(Required)
Maiden name (if applicable)
Email Address
(Required)
Mobile phone
(Required)
Home phone number
Is texting an acceptable way to reach you?
Yes
No
City
State
(Required)
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Zip Code
Date of Birth
(Required)
MM slash DD slash YYYY
U.S. citizenship status
U.S. Citizen
Permanent Resident/Green Card holder
Temporary resident/Visa holder
I am not a U.S. citizen and I do not have a Green Card or a Visa.
What is your ethnic background?
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latina
Native Hawaiian or Other Pacific Islander
White
Other
Are you a registered member of an American Indian (Native American) tribe?
Yes
No
What is your marital status?
Married
Engaged
Relationship (co-habitating)
Relationship (living separately)
Single
Divorced (finalized)
Divorced (in process)
Legally Separated
Separated (Non-legally)
Please list dates of all marriages, if applicable
Date
MM slash DD slash YYYY
Date
MM slash DD slash YYYY
If you have a partner or spouse, what is his/her name?
How did you hear about our agency?
Have you given birth before?
Yes
No
Are you currently pregnant?
Yes, I am currently pregnant.
No, I am not pregnant.
Have you had more than 3 C-sections?
Yes
No
Have you had more than 2 miscarriages? (Note we will request medical records.)
Yes
No
Are you currently a member of the US military?
Yes, and I am currently active.
Yes, but I am no longer active.
No, I've never been a member of the U.S. military.
Is your partner a member of the U.S. military?
Yes, and he/she is currently active. (You will need to provide proof (orders or commanding officer letter) that you won’t have to move for at least two years.)
Yes, but he/she is no longer active.
No, he/she has never been a member of the U.S. military.
If it were medically determined that the fetus has Down Syndrome and the intended parents chose to terminate the pregnancy, would you be willing to terminate the pregnancy at their request?
Yes
No
If it were medically determined that the fetus has a chromosomal abnormality other than Down Syndrome, such as spina bifida, and the intended parents chose to terminate the pregnancy, would you be willing to terminate the pregnancy at their request?
Yes
No
In the case of a pregnancy with multiples, if one fetus had a chromosomal abnormality/genetic condition/medical diagnosis that would affect quality of life, would you agree to selectively reduce if advised by a doctor and/or at intended parents' request?
Yes
No
BMI
Height
Weight(lbs.)
Have you ever tested positive for HIV?
Yes
No
Have you previously had chicken pox or received the varicella (chicken pox) vaccine?
I have had chicken pox.
I received the varicella vaccine.
I have neither had chicken pox nor received the vaccine, but I am willing to be vaccinated prior to becoming a surrogate.
I have neither had chicken pox nor received the vaccine and I am not willing to be vaccinated prior to becoming a surrogate.
Have you been vaccinated for MMR (measles, mumps, rubella)?
Yes
No, I have not had the MMR vaccine, but I am willing to be vaccinated prior to becoming a surrogate.
I have not had the MMR vaccine and I am not willing to be vaccinated prior to becoming a surrogate.
Do you currently smoke cigarettes or use tobacco products? (Please note: medical screening of surrogates includes a nicotine test.)
Yes
No
Were you ever a tobacco smoker? If yes, when and for how long?
Yes, presently
Yes, previously
No
since when?
(Required)
when and for how long?
(Required)
Do you have any history of smoking cigarettes or using tobacco products during any of your prior pregnancies? (NOTE: This will be verified on your medical records.)
Yes
No
Do you currently use recreational drugs, including marijuana?
Yes
No
Do you have a history of recreational drug use or alcohol abuse?
Yes
No
Have you taken any anti-depressants, anti-psychotics, or anti-anxiety medications in the past six months?
Yes
No
Have you ever taken anti-depressants, anti-psychotics, or anti-anxiety medications during a pregnancy? (Note: we will request medical records.)
Yes
No
Have you ever had a psychiatric hospitalization? If yes, when, where, and for how long?
Yes, before the age of 18
Yes, after the age of 18
No
Have you ever been diagnosed with any of the following? Check all that apply. (Please note: review of medical records is part of the screening process.)
Schizophrenia and/or Bipolar Disorder
Severe Post-Partum Depression
Post-Traumatic Stress Disorder
None of the Above
Have you or anyone in your household been convicted of a felony? (Please note: screening will involve a criminal background check on all adults in your household.)
Yes
No
Is any member of your household a registered sex offender?
Yes
No
Are you receiving any of the following additional forms of government financial assistance? (Check all that apply.)
Food Stamps
Medicaid
Cash Assistance/Welfare
Financial Aid
WIC
SSI
Public Housing/Section 8
Government Subsidized Childcare
Student Loans/Grants
Other (please specify)
None of the above
What is your highest level of completed education?
What is your occupation?
If you have a partner or spouse, what is his/her occupation?
Do you work in a state that is different from your state of residence?
What is your combined household annual income?
How much of this sum is yours? How much is your partner's? (We assume any remaining income is received from someone else living in the home.)
Do you and/or your partner have health insurance?
Both
Self
Partner
No
If you have health insurance, which of the following describes your insurance plan?
Employer sponsored (obtained through your job or a family member's job)
Individual plan (you or a family member signed up for directly through the insurance company)
*Government/state sponsored plan (e.g. Medicaid)
Do you anticipate any changes to your health insurance in the next 12-24 months?
Yes
No
Have you ever been arrested?(Please note: screening includes background checks. We may request arrest reports and/or explanation letters.)
Yes
No
Has your partner/spouse ever been arrested? (Please note: screening involves background checks on anyone over 18 in your household. We may request arrest reports and/or explanation letters.)
Yes
No
Do you or your partner currently have any outstanding legal obligations (divorce proceedings, lawsuits, misdemeanor, and/or other criminal offenses)?
Yes
No
Have you or your partner ever filed for bankruptcy?
Yes
No
Do you and/or your partner have any past, current, or ongoing open cases with Child Protective Services? If yes, what date(s), under what circumstances, and what was the outcome? (Please note: we will request any necessary documentation for any cases.)
Please list the full legal names of any persons over the age of 18 living in your home.
Which form(s) of birth control are you currently using? Check all that apply.
Birth Control Pills
NuvaRing
Diaphram
Patch
Implanon/Nexplanon
Tubal Ligation
Partner Vasectomy
Condoms
IUD
Essure
Depo Shot
I am not currently using any forms of birth control.
Other
Please specify
(Required)
Which form(s) of birth control have you used in the past two years?
Birth Control Pills
NuvaRing
Diaphram
Patch
Implanon/Nexplanon
Tubal Ligation
Partner Vasectomy
Condoms
IUD
Essure
Depo Shot
Other (please specify)
I have not used any form of birth control in the past two years.
Please specify
If you are using an IUD or implant, would you be willing to have it removed prior to your agency screening?
Yes
No
I am not using an IUD or implant
Has your partner ever been prescribed anti-depressants, anti-anxiety, or psychiatric medications? If yes, please list what medications, how long he/she used them, and when he/she stopped using them.
Yes
No
Does your partner use recreational drugs, including marijuana? If yes, what kind(s) and how often?
Yes
No
Have you been a surrogate before?
Yes, and I carried the baby(ies) to term. Please list how they were delivered (vaginal, c-section), at how many weeks gestation, and date of birth)
Yes, but I did not carry the baby(ies) to term.
Yes, and I matched with intended parents but never became pregnant.
No, I have never been a surrogate before.
How many children (biological or nonbiological) are living in your home?
How many biological children do you have? Please list how they were delivered (vaginally, C-section), at how many weeks of gestation, and date(s) of birth. (Note: screening includes a review of medical records for previous pregnancies and deliveries.)
Number of biological children:
1
2
Child 1
Method of Delivery:
Weeks of Gestation:
Birth Weight:
Date of Birth:
MM slash DD slash YYYY
Child 2
Method of Delivery:
Weeks of Gestation:
Birth Weight:
Date of Birth
MM slash DD slash YYYY
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Are you currently nursing or pumping breast milk?
Yes, but I have resumed normal menstrual cycles.
Yes, and I have not yet resumed normal menstrual cycles.
No, I am not currently breastfeeding.
Did you experience any complications during your pregnancy(ies)? If yes, please explain.
Yes
No
Please explain
Check off the following reproductive conditions with which you have been diagnosed.
Endometriosis
Ovarian Cysts
Pelvic Inflammatory Disease
Ectopic Pregnancy
Pre-Eclampsia
Pregnancy Induced Hypertension
Placenta Previa
Gestational Diabetes
Complications with Estrogen or Progesterone
Pre-Term Labor (before 37 weeks)
Excessive Bleeding or Hemorrhage
Intra Uterine Growth Restriction (IUGR)
Shortened Cervix
None of the above
Other
Have you ever had a heterotopic or ectopic pregnancy?
Yes
No
Have you ever experienced (a) miscarriage(s)?
Yes
No
Please list how many, the year(s), number of weeks of gestation, and whether a D&C/D&E was needed.
(Required)
Have you ever experienced (a) still birth(s)?
Yes
No
Please list how many, the year(s), and number of weeks of gestation.
(Required)
Have you ever terminated a pregnancy?
Yes
No
Please list the year.
(Required)
Check off any of the following conditions with which you have been diagnosed.
Tuberculosis
Rubella (German Measles)
Serious Birth Defects
Diabetes
Liver or Renal Disease
Heart Attack Before 50
Severe Bleeding Tendency
Cystic Fibrosis
Neurofibromatosis
Progressive Kidney Disease
Congenital Heart Defects
Seizure Disorder
Cataracts (before age 40)
Rheumatoid Arthritis
Cancer
Other
None of the above
Diabetes – Please elaborate if diet controlled or insulin controlled
Do you currently take prescription and/or over-the-counter medications? If yes, please list them below.
Yes
No
Please list any surgeries you have had and their dates.
Does anyone living in your home smoke?
Yes
Yes, but he/she is willing to smoke outside of the home.
No
In the past six months, have you been diagnosed with a Zika virus infection?
Yes
No
Do you have any plans to travel outside the country within the next 1-2 years?
Yes
No