Gestational Carriers
Application

Application Gestational Carrier Candidate

Personal Information:





Educational Information:


Are you employed?*
YesNo
If you have answered yes, what is your occupation?



Relationship Status:



Is he/she employed?
YesNo
If you have answered yes, what is your occupation?



Are you married?
YesNo
If yes, when was your wedding date?

If No, Are you Engaged?
YesNo
If not married or engaged, are you in a relationship?
YesNo
Children/Pregnancy History

For each of these children, please provide the following info (Name, DOB, Sex, Birth Weight):

Were all of your children born healthy?
YesNo
If you have answered no, please explain:

Do you enjoy being pregnant?
YesNo
Do you intend to add more children to your own family?
YesNo
Have you ever had any abortions, miscarriages or stillbirths?
YesNo
If you have answered yes, please describe the timing and circumstances of each:

Were any of your children born prematurely or were there any complications with delivery?
YesNo
If the answer is yes, please describe the circumstances of each birth:

Medical
Do you currently take any prescription medications?
YesNo
If you have answered yes, please list the name, the dosage, the purpose of each medication, and whether or not you were on the medication during previous pregnancy(ies)

Do you currently Smoke?
YesNo
Do you currently use illegal drugs?
YesNo
Do you currently Drink Alcohol?
YesNo
If yes, how many drinks (on average) per: Day:

If yes, how many drinks (on average) per: Week:

If yes, how many drinks (on average) per: Month:



Date of last OB visit:

Do you have health insurance?
YesNo
If yes, name of your insurance company