Gestational Carrier Medical Evaluation Questionnaire
Please complete this questionnaire to help us assess your medical suitability as a gestational carrier. All information is confidential and used solely for evaluation purposes.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Do you currently have health insurance?
*
Yes
No
Have you ever had any of the following medical conditions?
*
Diabetes
Hypertension
Thyroid Disorders
Blood Clotting Disorders
None of the above
Other
Please list any medications you are currently taking.
Please list any allergies (medication, food, environmental).
Reproductive History
*
Rows
Number
Complications
Full-term pregnancies
Preterm pregnancies
Miscarriages
Live births
Have you ever had a cesarean section?
*
Yes
No
Do you currently smoke, use alcohol, or recreational drugs?
*
Smoke
Alcohol
Recreational Drugs
None
Height (in cm)
*
Weight (in kg)
*
Please provide any additional relevant medical history.
Signature
*
Submit Questionnaire
Submit Questionnaire
Should be Empty: