Surrogate Mother Profile - Newport Beach, CA - Coastal Surrogacy LLC
 
 
 
 
 
 

SAMPLE SURROGATE PROFILE IN CALIFORNIA

 

Applicant ID # 001289

 
 
Personal Information:
 
Age: 32
 
State of Birth: CA
 
Country of Birth: USA
 
Partner Information:
Marital Status/History: Married
How long have you been married and/or in your current relationship? 11 years
How would you describe your relationship with your partner?
Excellent, we have a great relationship built on mutual trust and respect
Is your partner supportive of your decision to become a surrogate? Yes
Please explain:
 
Employment History:
Current Occupation: stay at home mom
Years at current employment: 2
Years at previous employment: 10
Years at current employment: 2
Current hours worked / week: n/a
 
General Information:
Would you require day care/baby sitting to attend any appointments associated with the ovum donation/surrogacy procedure? Yes
Do you own a car? Yes
If no, do you have alternate reliable transportation?
 
Personal Profile:
Religion: Christian
Practicing? Yes
Blood type: O positive
Height: 5 Ft 3 In
Weight: 124 Pounds
BMI: 22
 
Personal Questions:
How is your overall health?: Excellent, no health problems
(medical/dental/fertility)
Have you ever been diagnosed with the following?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
If you mark the box to any of the above conditions, please explain:

Have you ever been diagnosed and/or treated for Cancer? No
If yes, please explain:

Have you ever been diagnosed and/or treated for Asherman's Syndrome? No
If yes, please explain:

Are you currently a smoker? No
If you smoke, how much? Packs/Day
If you have quit, what was the approximate date? 0000
Does anyone in your household smoke? No
If yes, please explain:

Do you drink alcohol? No
If yes, how much? /Week

Do you or have you used any non-prescription drugs? Yes
If yes, please describe: Over the counter medications for colds, flu etc.

Do you or have you used any prescription drugs? Yes
If yes, please describe: Whatever prescribed, antibiotics etc. Medications for surrogacy cycle

Do you or have you used any illegal drugs? No
If yes, please describe:

Have you ever had a drug or alcohol abuse problem? No
If yes, please describe:

Are you currently suffering from and/or been diagnosed or treated for Anorexia/Bulimia? No
If yes, please describe:

Have you ever been under the care of a Psychiatrist? No
If yes, please describe:

Have you ever been under the care of a Psychologist/Family Therapist? Yes
If yes, please describe: Screening for surrogacy

Have you ever had any psychiatric hospitalizations? No
If yes, please describe:

Have you ever experienced any depression or suicidal thoughts? No
If yes, please describe:

Have you ever been arrested or convicted of a crime? No
If yes, please describe:

Have you ever had surgery of any type? (including cosmetic surgery) No
If yes, please describe:

Have you ever had a blood transfusion? No
If yes, please describe:

Have you ever been diagnosed with an STD? No
If yes, please describe:

Do you have any tattoos? Yes
Approximate date of your last tattoo? 2007
 
Fertility Profile:
Age when you first started your menstrual cycle: 13
Are your cycles regular? Yes
How many days between your monthly cycle? 28
Date of last cycle: 2010
What is the birth control you are currently using? birth control pill
How many children do you have living with you? 3
What are their ages? 10, 8, 3
How many pregnancies have you had? 4
How many resulted in a live birth? 4
Did any pregnancies result in a miscarriage? No
If yes, how many and please explain the details:

Did you experience any complications during your pregnancies or during delivery? No
If yes, please explain:

(Both your own personal pregnancy and any previous surrogacy)
Did any birth(s) result in a Cesarean Section? No
If yes, please explain:

Have you ever terminated a pregnancy? No
Have you had any trouble becoming pregnant? (taking longer than six months) No
If yes, please explain:

Have your parents or siblings experienced difficulties becoming pregnant? (conceiving) No
If yes, please explain:

Was your mother administered diethylstilbestrol (DES) or any other prescription drug while she was pregnant with you? No
If yes, please list the known prescriptions and the reason it was prescribed:

Have you ever had any of the following?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
If you mark the box to any of the above conditions, please explain: N/A
 
Delivery History:
 
1
1
2
3
4
5
6
 
Delivery Date
1999
2001
2006
2009
0000
0000
 
Birth Weight
8 lbs
7 lbs
7 lbs
6.10 lbs
lbs
lbs
 
Length of Labor
30 hrs
25 hrs
9 hrs
3 hrs
hrs
hrs
 
Single/Multiple
Single
Single
Single
Single
 
Vaginal/C-Section
Vaginal
Vaginal
Vaginal
Vaginal
 
 
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.