Surrogate Sample Profile

Sample Surrogate Profile

Surrogate #: SU 6000

This profile is a compilation obtained from an 14-page application that has been completed by the fertility helper.

PERSONAL INFORMATION

Date of Birth: 7/13/1981

Race: Caucasian                                                    Ethnic History: Irish, German

Hair Color: Blonde                                    

Eye Color: Blue                                                       Weight (lbs): 125 lbs

Blood Type: O+                                          

Height: 5'5''                                                              Illegal Drug Use: Never

Religion: Catholic                                                  Criminal Record: No

Smoker: No                                                            How Often: N/A                                   

Alcohol Consumption: Yes                                 How Often: 2-3 times per month

PREGNANCIES

Number of Pregnancies: 1                                Number of Abortions: 0        Year:

Number of Children: 1                                        Number of Micarriages: 0      Year:      

INFORMATION ABOUT PREGNANCIES

Present Method Of Birth Control: Birth Control Pill

EDUCATIONAL /VOCATIONAL HISTORY

Education: Bachelor's Degree in Earth Science and Environmental Studies and a Master's Degree in Environmental Science.

Plans for Additional Education:  I am currently working on a PH.D. in Geophysics.

Hobbies and Special Interests: I enjoy singing, cooking, sports, helping the community, reading, symphonies, and art showings.

Employment History: I am currently a Graduate Teaching Assistant.

MEDICAL HISTORY

Vision: Good                                              Hearing: Good

Sexually Transmitted Diseases: None

Previous Hospitalizations/Surgery:  1999 - tonsillectomy                                              

Previous Psychiatric History: None

Allergies: Penicillin

Exercise Program: Regular

Diet: Healthy diet, eats a lot of vegetables and lean meats, 6 glasses of water a day

Type of Exercise: She does Yoga 3-4 times a week, climbs at the gym 5 days a week for about a half hour. Lifts weights 1 or 2 days a week, and also tries to climb outdoors one day on the weekend. She runs with her dog for a half hour 3-5 times a week and rides her bike to work (3.5 miles one way).

PERSONAL MESSAGE FROM THE FERTILITY HELPER

Why do you want to help the prospective parent(s)?  

I want 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 parent(s), 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!

Have you been a surrogate 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 be a surrogate and know what it takes emotionally and physically.

Who would provide emotional support for you during the entire procedure (e.g. spouse, parents, relatives, friends)?

My husband and family are supportive of my decision to become a surrogate.

Your spouse or significant other must verify their acceptance of your participation in this program. How does he feel about your participation?

He is supportive in my decision, and also very excited to be apart of this process.

Would you expect or desire emotional support from the intended parents and how important is their support to you?

It would be nice to have support, 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 parents. An annual letter and photo would ideal.

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 you when making your decision to be a surrogate:
(1=most important through 5=least important)

1 - Giving someone else a child would make me very 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 more children of my own.