Hyperemesis Gravida (severe nausea)
RH Factor
Group B Strep
Uterine Biopsy
Post-Partum Depression
Complications/Sensitivity to Estrogen or Progesterone
If you mark the box to any of the above conditions, please explain:
N/A
Delivery History:
Delivery Date
Birth Weight
Length of Labor
Single/Multiple
Vaginal/C-Section
1
1999
8lbs
30hrs
Single
Vaginal
2
2001
7lbs
25hrs
Single
Vaginal
3
2006
7lbs
9hrs
Single
Vaginal
4
2009
6.10lbs
3hrs
Single
Vaginal
5
0000
lbs
hrs
6
0000
lbs
hrs
Character Profile:
How would you describe your
personality?
Friendly, out-going, lots of engery. I love being active and outdoors. Honesty and integrity mean a lot to me.
(Quiet, Energetic, Artistic,
Etc.)
Describe you special interests,
hobbies, talents:
Health and fitness is my hobby and passion. I was a gymnist for 15 years and I also coach gymnastics. My children are actively involved in sports so my main interest is my family.
Do you have any special goals
you are working towards?
We are working towards buying a home. I would love to be able to give my girls a home that is our own.
(personal or professional)
Do you participate in any sports or recreational
activities?
Yes
If yes, please describe:
Coaching gymnastics, sports with my kids, camping
How do you view other women/people who have suffered with infertility or
experienced difficulty with becoming pregnant or having family of their own?
I feel terrible, it is truly a tragedy. My heart aches for people who want a child so badly.
How did you become interested in Surrogacy?
I had a friend who experienced infertility and I wanted nothing more than to help her but she finally was able to conceive and delivered a healthy baby. I still was drawn to the idea of helping somone in this capacity.
What does being a Surrogate Mother mean to you?
It's just a blessing to have the opportunity to do this for someone that really wants and deserves to be a parent.
Why do you want to be a Surrogate Mother?
I loved my first experience as a surrogate so much that I knew in my heart that I was not done yet.
What to you hope to accomplish by becoming a Surrogate Mother?
Well having already been a surrogate before, I am just very excited to be doing this again!
How supportive is your extended family or friends of your decision to become
a Surrogate Mother?
They are very supportive and know that this is what is in my heart.
Compatibility Questions:
How do you feel about being matched with a single parent (male or female)?
I dont have any preference, I feel this does not determine who should be a parent.
How do you feel about being matched with a same sex (gay) couple or individual?
I have no preference, again I dont feel that this should determine who is or is not a good parent.
How important is it for you to become matched with a couple or individual who
shares your same religion/religious beliefs?
It is not important to me but I do feel that we should share the same goals for this process.
How do you feel about working with someone who already has a child verses
someone who has no children?
I have no preference.
When considering a couple, are you open to working with a couple/individual
who
resides outside of the
Southern California area (someone who might live
out of theState/Country)?
Open to any
How much contact or communication are you looking for from the couple/individual
during the pregnancy and what type of contact do you prefer (example, in person,
accompanying you to your appointments, telephone, email, combination)?
I would like to stay in touch, regular communication by email and phone is fine, it is not necessary for the parents to attend all my medical appointments.
How much contact are you looking for following the birth of the child and what
is
the main form of preferred contact (letters, email, telephone, in person)?
Whatever everyone feels comfortable with. I am open to any.
How would you feel about pumping breast milk if requested by the Intended
Parent(s)
following the birth of the child(ren)?
I am fine with this!
Regarding the embryo transfer procedure, what is the number of embryos you
feel most
comfortable with being transferred to your uterus?
Whatever is medically appropriate
Understanding that in an IVF procedure, there will be generally more than one
embryo
transferred to your uterus to help maximize the chance for conceiving
a pregnancy, are you
comfortable with the possibility of carrying twins?
Yes, of course!
Are you comfortable with the possibility of carrying triplets?
I would prefer to carry no more than twins.
What are your feelings on Fetal/Selective Reduction (if your attending physician
determines
it becomes medically necessary to reduce (terminate one or more
fetus(s’)) to a safe number
for example reduce from triplets to twins etc. if it was
recommended to provide a safer
environment for yourself and the remaining
fetus(s’) and/or to save the pregnancy from risk
of miscarriage etc.?
I am open to this if this is medically necessary.
What are your feelings on terminating a pregnancy for medical reasons (for
example, if the
child was found to have an abnormality that would affect
his/her quality of life and/or pose
risk a greater risk of death or suffering
following the birth, or if your life was at risk)?
I feel this should be the parents decision.
Do you have any special requests or other desired criteria you would like
to add when
considering working with a couple/individual?
No, just am excited to get started!
Educational Profile:
Are you currently a student?
No
What is your current GPA?
What is your current Major?
Highest level of education completed:
College Degree
Degree/Diploma/Certification:
Bachelors
What are your ultimate
career goals or desires?
When my children are older I will pursue a career in marketing and management.
