• Full name _________ Tel. __ +
• 1. Date of birth __ __ blood type _ Height _weight__
• 2. Country and city of permanent residence _____________
• 3. Nationality _____________ Education ___
• 4. Marital status (underline): not married / married / divorced not married
• Name of husband ____________________
• 5. Children, their age _ / _ _ _ Height / weight of the latter at birth _____
• 6. Employment: part-time / do not work / study / work from home does not work
• 7. Position at the place of work _______________
• 8. Number of pregnancies ___ Number of abortions __ miscarriages_
• 9. the first day of the last cycle _
• 10. Participation in the surrogacy program earlier: yes / no - no
•	If yes:

• Number of programs ___
• Number of successful programs (baby was born) ___
• Number of unsuccessful programs (no pregnancy) __
• Number of terminated pregnancies no_
• 11. Participation in donor programs: yes / no, if yes, how many times _no__
• 12. The course of pregnancy, complications ___ without _________
• ________________________
• 13. Complications during childbirth ____ no _____________
• 14. Transferred surgical operations ___ no ________
• _______________________
• 15. Past injuries _____________
• 16. Hereditary diseases ____________
• 17. Chronic diseases _____________
• 18. Are you currently undergoing any treatment _________
• _______________________
• 19. Have you ever used drugs: yes / no - no
• 20. Attitude to alcohol ______ to smoking ___
• 21. Are you under investigation: yes / no no
• 22. Previous convictions: yes / no no
• 23. Information provided: Fluorography ___ PND_no__ ND__no
• 24. The presence of ultrasound of the pelvic organs: _ I attach __ \ no ____
• 25. Readiness to move full / partial
• 26. Desired Fee
• 27. are ready for a full relocation program for the entire period of pregnancy