Fertility Bridges Surrogates
First Name Only:
Type of work you do:
Type of work partner does:
# of years together:
Birth dates, weights and names of children:
1. Were your children full term? If not, explain.
2. Were your children healthy at birth?
3. Any health issues with children now?
4. Any trouble getting pregnant?
5. Are your children biologically related to your partner?
6. Any children given up for adoption?
7. Who do you live with?
8. Do other family members live near you?
9. What support will you have during your pregnancy?
10. Do your partner and family support your decision to be a surrogate?
11. Do you have child care? If so, who? Cost?
12. Would you like child care assistance during the pregnancy?
13. If you have a partner, are they in good health?
1. Do you smoke?
2. How often do you drink?
3. Take any drugs?
4. Take any prescription medicine?
5. Does your partner smoke?
6. Length of menstrual cycle. (28 days?)
7. How many days is your period? (5 days?)
8. Birth control method
9. Any family history of disease? Cancer? Health problems?
10. Any family history of fertility problems?
11. Any current or past health concerns?
12. Have you ever seen a therapist?
13. Any hospitalizations?
14. How often do you go the doctor?
15. When was your last pap smear?
16. What were the results?
17. How often do your children go to the doctor?
18. Do you have any allergies?
19. Do your children have allergies?
1. Do you have car insurance?
2. Do you have Life Insurance?
3. What kind of Health Insurance do you have?
4. Does your health insurance cover your surrogate pregnancy?
5. Have you double checked this? (It is best to call and ask for a manager and ask if
they specifically “exclude” surrogacy in your plan.
1. Why have you decided to become a surrogate?
2. How long have you been thinking about surrogacy?
3. Have you spoken with other potential parents or agencies about it? If so, please
4. What kind of relationship would you like to have with the intended parents of this
5. Describe your pregnancies.
6. Did you have morning sickness?
7. Any food cravings?
8. Did you feel emotionally fragile? Elated? Tired?
9. How was your mood in general?
10. Describe your deliveries.
11. How do you feel about shots?
12. Are you familiar with the fertility drugs you need to take before and during
pregnancy? If not, please research on your own or visit links below and then
To learn about the IVF process you can visit:
For a sample list of gestational carrier medicine visit:
13. What are your thoughts about taking fertility drugs?
14. Would you terminate the pregnancy for a chromosomal abnormality like Down
15. Would you reduce to twins from triplets or more?
16. Have you ever had a miscarriage or abortion? If so describe the situation and
your feelings about it.
17. Describe your lifestyle.
18. What do you like to do for fun?
19. What is your favorite vacation?
20. How do you pamper yourself?
21. Describe your diet. What do you normally eat for breakfast, lunch, dinner,
22. Do you like to cook or do you eat out mostly?
23. Any food allergies?
24. Describe the home you live in and your neighborhood.
25. Anything you would like to add about yourself?