Have you ever had major radiation or X-ray exposure :
Have you ever been treated for syphilis :
Have you ever been treated for gonorrhea :
Have you or any of your sexual partners had: NSU (non-specific urethritis)
Other sexually transmissible diseases
Have you ever had any major illnesses such as amoebic dysentery, hepatitis, pneumonia, mononucleosis, etc.:
Any current chronic medical problems / conditions :
PERSONAL HEALTH : WORK HISTORY / EXPOSURE
PERSONAL AND MOTIVATIONAL In your own words, describe your personality and character:
What are your hobbies, interests, and talents:
If you could pass on a message to the child you are carrying for the couple, what would that message be:
Why do you want to be a surrogate mother :
How do you feel about aborting a fetus in the case of medical defects or medical recommendation :
How do feel about reducing the pregnancy in the case of multiple fetuses :
SURROGATE APPLICATION FORM Would you participate in this procedure for an infertile couple ONLY :
Would you work with a couple with children :
Are you willing to work with a single woman or man :
Please, share your reasons for your preference :
Do you foresee any possible emotional reactions or problems you might have during the surrogate parenting process ?. (testing, injections, or delivery).
Have you discussed surrogacy with your family and do they approve ?
If not, when do you plan on discussing it with them ?
Who would you have to provide you with emotional support during the entire procedure. (e.g. husband, parents, relatives, friends, etc.)
Is your spouse or companion aware of your interest in the program, and if so, how does he feel about you participation ?
Would you expect or desire emotional support from the couple ?
To what extent is payment for this service a necessary requirement for you :
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