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Surrogate Initial Screening Questionnaire
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Last Name
*
Your answer
First Name
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Your answer
Email Address
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Your answer
Phone Number
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Your answer
What is your current age?
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Your answer
Date of Birth
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MM
/
DD
/
YYYY
Are you a smoker?
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Yes
No
Do you live in a smoke free home?
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Yes
No
Full Home Address Where You Will Reside During Pregnancy (Address, City, State, Zip)
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Your answer
Any History of Mental Health Treatment for Yourself or Family?
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Your answer
Have You Given Birth and are Raising at Least One Child?*
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Yes
No
Number of Children, Children's ages, and their living status?
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Your answer
Are You Able to Provide Uncomplicated Pregnancies and Deliveries With Documentation in Prenatal and Delivery Record?
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Your answer
Any Criminal History?
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Your answer
Any History of Drug Usage?
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Your answer
Any History of a Sexually Transmitted Disease of Any Kind?
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Your answer
Do you have health insurance?
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Yes
No
Are you currently on any governmental assistance?
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Yes
No
How did you learn about Surrogacy Miracles & Consulting?
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Your answer
Are You Able to Commit to the Responsibilities and Requirements to Be a Surrogate?
*
Yes
No
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