Intended Parent Questionnaire

Intended Parent #1 should fill out this section (REQUIRED).

First Name

Last Name

Are You Currently Married?

YES NO

Occupation

ANY ONGOING HEALTH ISSUES?

HOW WOULD YOU DESCRIBE YOUR PERSONALITY?

ANY SPECIAL TALENTS, INTERESTS, OR HOBBIES?

Intended Parent #2 should fill out this section (NOT REQUIRED IF ONE PARENT HOUSEHOLD).

First Name

Last Name

Occupation

ANY ONGOING HEALTH ISSUES?

HOW WOULD YOU DESCRIBE YOUR PERSONALITY?

ANY SPECIAL TALENTS, INTERESTS, OR HOBBIES?

Intended Parent #1 AND #2 should fill out this section together.

PRIMARY LANGUAGE SPOKEN IN HOME

HOW WOULD YOU DESCRIBE YOUR HOUSEHOLD?

DO YOU CURRENTLY HAVE ANY CHILDREN?

YES NO

IF YES, HOW MANY AND HOW OLD?

INTENDED PARENT #1 & #2 HAVE YOU EVER BEEN SCREENED FOR INFECTIOUS DISEASES?

YES NO

IF YES, WHAT DISEASE(S)

INTENDED PARENT #1 & #2 DO YOU HAVE ANY ARRESTS OR CONVICTIONS?

YES NO

IF YES, WHAT DISEASE(S)

HOW MANY EMBRYOS DO YOU CURRENTLY HAVE?

HOW MANY EMBRYO(S) WOULD YOU LIKE TO TRANSFER?

WHAT LEVEL OF COMMUNICATION WOULD YOU PREFER BEFORE, DURING AND AFTER THE PREGNANCY WITH A SURROGATE?

WHAT ARE YOUR THOUGHTS ON TERMINATION & REDUCTION?