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SURROGATE PROFILE SU# 6000 This profile is a compilation of information obtained from an 18-page application that has been completed by the Fertility Helper. PERSONAL INFORMATION First Name: Maire Surrogate Fee: $18,000 Date of Birth: 12-09-80 Hair Color: Dark Brown Complexion: Medium Hair Type: Straight Eye Color: Hazel Race: Caucasian Blood Type: B+ Ethnic History: French, Swedish, Italian Religion: Lutheran Height: 5'6'' Weight (lbs): 130 lbs Smoker: No How Often: None Alcohol Consumption: Yes, wine and liquor How Often: 3 times a month Illegal Drug Use: No Criminal Record: No PREGNANCIES Number of Pregnancies: 2 Number of Abortions: 0 Year: Number of Children: 2 Number of Miscarriages: 0 Year: Present Method of Birth Control: IUD Names and Birth Date(s) of Children:
INFORMATION ABOUT PREGNANCIES
FAMILIAL HEALTH HISTORY Number of Blood-Related Siblings: 3 Number of Twins in Family Tree: 1 set Special Achievements of Family Members: Grandfather was WWII Vet, Mother has a PH.D. in Psychology. LONGEVITY (Please remember that older grandparents may not have had the benefit of modern medicine.)
FAMILY MEDICAL HISTORY Each Fertility Helper was provided with a list of 70 different medical conditions to review including: heart and circulatory conditions, blood disorders, respiratory conditions, illnesses affecting sight/sound/smell, neurological conditions, skin disorders, mental health problems, reproductive system disorders, metabolic disorders, and disorders of the internal organ systems. This Fertility Helper identified the following conditions in her family members:
IARC understands that some clients would like updated medical information about the genetic makeup of the child. In order to maintain some degree of anonymity between the parties. IARC will contact all willing ovum donors/surrogates by mail on an annual basis to receive updated medical information that can be passed on to the child's parents. Each Fertility Helper is asked to choose either no contact or contact for 1 year, 2 years, 3-5 years, 10 years or more than 10 years. This Fertility Helper has agreed to maintain contact for: more than 10 years EDUCATIONAL/VOCATIONAL HISTORY Education: Bachelor of Fine Arts Hobbies and Special Interests: reading, jogging, painting, and sculpting Volunteer Work: Volunteer at church every week. MEDICAL HISTORY Vision: Perfect Hearing: Perfect Condition of Teeth: Perfect Allergies: None Sexually Transmitted Diseases: None Previous Hospitalization/Surgery: birth of children Previous Psychiatric History: None Diet: Average Diet Exercise Program: Regularly Type of exercise: yoga, jogging, and running after kids!! MOTIVATION Have you been a surrogate mother previously? If so, please tell us about your experience. No Do you foresee any possible emotional reactions or problems you might have during the surrogate parenting process (testing, inseminations, injections and/or delivery)? What do you feel would be the most likely to happen to you? None, I feel secure in my decision to become a surrogate and know what it take emotionally and physically. Who would provide emotional support for you during the entire prodecure (e.g. spouse, parents, relatives, friends)? My husband, and family are very suportive of my decision to become a surrogate. Your spouse or significant other must verify their acceptance of our participation in this program. How do they feel about your participation? My husband is very supportive in my decision, and is also very excited to be apart of this process. Would you expect or desire emotional support from the infertile couple and how important is their support to you? It would be nice to have that support from the couple, but whatever the parents are comfortable with. Would you expect any contact or information about the child after birth? That is entirely up to the intended parent(s). An annual letter and photo would be nice. Would you be willing to undergo an amniocentesis if requested by the client or doctor? Yes Would you be willing to undergo a therapeutic abortion if it were determined the child would be severly physically or mentally handicapped, or if your own life were in danger? If your medical doctor deemed it necessary. would you be willing to undergo an abortion? Yes, I leave the decision entirely upon the parents regarding their child. Are there specific conditions under which you would NOT abort a pregnancy? For minor conditions (ex. Cleft Palate). Please rate the following factors in order of importance to you when making your decision to be a surrogate: (1=most important through 4=least important.) 1- Giving someone else a child would make me vey happy. 4- I need the money very much. 2- I think people who want children should have them. 3- I like being pregnant but do not want more children of my own. To what extent is payment for this service a necessary requirement for you? I feel that payment comes secondary to the opportunity of giving a life to someone. Compensation for my time and effort is something I must also consider. PERSONAL MESSAGE FROM THE FERTILTIY HELPER Why do you want to help the prospective parent(s)? I want to do this for prospective parents because my children have changed my life and have made me a better person. I love to watch them grow and learn, it is truly amazing. In your own words, describe your personality and character: I love to have fun and love trying new things. I am very creative and love doing arts and crafts. If you could pass a message to the prospective parents, what would that message be? I wish you the best of luck in your journey to parenthood. I look forward to having the opportunity of helping you achieve your dreams! |
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