Surrogate Intake Application

Name: Wendy

Location: Lancaster, CA

Age: 35

Height: 5ft

Weight: 144lbs

BMI: 24.0

Relationship Status: Single

Do you have any pets? No

Do you have any guns in your household? No

Do you own or lease a car? Yes

Do you have a driver’s license? Yes

Is your car insured? Yes

Total Pregnancies: 5

Are you covid vaccinated? No

Have you or your spouse ever served time in jail? If yes, how much time did you serve and for what? No

Do your menstrual cycles occur monthly? Yes

Do you or any members of your household smoke or ingest marijuana? If so, where and how often? No

Do you drink alcohol? If yes, how much and how often? No

Did you suffer any emotional or physical problems during and/or after each of your pregnancies? If yes please explain. No

Have any of your children had or do they have difficulties learning or birth defects? No

Do any of your children have serious health problems? If yes, please explain. No

Have you ever had any surgery? If yes, reason and results? Appendix

Have you ever experienced any postpartum depression? If yes, please give the details and time periods. No

Have you ever been prescribed any medication for depression or mental health? If yes, please list medication name, reason for use and dates of use. No

Have you ever had any problems with drug or alcohol abuse? If yes, please explain. No

Do you have any allergies? If yes, please explain in detail. No

Are you with a sexual partner now? No

Are you currently on birth control? No

What is your monthly income? $2,000 Cashier

What is your highest level of education? College

How many embryos are you willing to transfer? 1

In case of multiple pregnancies are you willing to reduce? yes

How much communication with the IPs do you expect during your surrogacy? If they feel the need to contact i have no issues

Will you permit the parents in the delivery room? Yes

Can you tell us about your support system? Daughter (17), two best friends, ex partner (father of the kids)