surrogate mother's questionnaire
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- Joined: Tue Feb 22, 2022 2:04 pm
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