surrogate mother's questionnaire

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Marina Shnuskina
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Joined: Tue Feb 22, 2022 2:04 pm

surrogate mother's questionnaire

Post by Marina Shnuskina »

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surrogate mother's questionnaire

SURROGATE MOTHER'S PROFILE NO. _____ _:

Before filling out the questionnaire, we remind you of the MANDATORY
conditions for donors::

FCs:

Name: Middle name: Date of birth::
Salome 1-04-1994

Nationality: Citizenship::
Cameroonian

race:

hair color:
Blondes



Eye color:
black



Your social media page::

Address (place of residence)::

Cameroon

Body type::
lean

Height::
1.70

Weight::
65

Blood type::
1

Rh factor::
(+)

Do you play sports::
Yes

Who lives with you::
daughter

Received specialty::

Education::
Higher

Marital status::
Not married

Number of marriages::
0

Please indicate the birth control devices that you are currently using::

condoms

cycle regularity::
Regular

Cycle duration:
29

Are you currently lactating?:
no

Have you ever had any experience with surrogacy::
Yes

Have you ever had any experience of donation::
no

How did you get information about surrogacy?::
The Internet

Why did you decide to participate in the Surrogacy program?::
To help assist to complete a family

What type of relationship with your family/child do you expect to have
after completing the program?::
No relationship

What do you say to the couple who chose you as a surrogate mother to
convince them that you will not change your mind after you give birth to
their child?::
I will relocate or I can back to country am ready to sign any documents
they want me to

How do you plan to spend the amount of money received for participating
in the Surrogacy program?::
Open a business back in my country to help take care of my baby

What would you say if a child born to you in the Surrogacy program wants
to meet you?::
It will depend on the parents decision if they want me to meet him I
will otherwise I will not

I have read and accept the rules of the public offer:
Yes

Date:
01/18/2022

Number:
1

Skinny:
Medium

Do you play sports?:
Yes

Living conditions:
Average

Who lives with you:
Daughter

Marital status:
Not married

Number of marriages:
1

Information about children:

Number of children, their age and gender:
One child 1year 4 months

Dates of birth of children:
7 September 2020

Height and weight of children at birth:
Height 0.5meter weight 3.30kg

The course of pregnancy:

Due date (in obstetric weeks):

Specify the due date of each child:

Diseases of children after childbirth:
Non

The way of delivery:
Vagina delivery

Information about abortions and miscarriages:
Non

Abortions, miscarriages, ectopic pregnancy, caesarean section (how many
and when) Information about bad habits Smoking Alcohol Drugs:

Information about bad habits:

Information about sexually transmitted diseases:
Non

Do you have hereditary, chronic diseases:
Non

Postponed operations:
No operation

The contraceptives you are currently using:
Withdrawal method and condoms

Start date of the last cycle:
31 Dec 2021

Date of filling out the questionnaire:
18 Jan 2021


Consent to the processing of personal data:
I agree to the processing of personal data
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