Section 7
MEDICAL/SOCIAL HISTORY: Please answer the following questions to the best of your ability. If any questions are answered "yes," give a complete explanation at the end of this section
Have you, your children, or anyone in your family ever had any of the following:
A. Seizures, fainting spells, paralysis, nervous or mental disorders, dizziness, or any other disorder of the heart or blood vessels?
B. Asthma, emphysema, shortness of breath, chronic cough, or any other disorder of the lungs?
C. Frequent or recurrent abdominal pain, bleeding from or disease of the stomach, intestines, gallbladder, or liver, indigestion, ulcers, diarrhea, or colitis?
D. Sugar, protein, or blood in the urine; kidney stone or any other disorder of the kidneys, bladder, or prostate?
E-1. Any disorder of the uterus or ovaries, any venereal disease, or any type of complications during or as a result of pregnancy?
E-2. Have you ever had a C-section, or any other difficult with pregnancy?
E-3. Have you ever had a miscarriage or stillbirth?
F. Diabetes, thyroid, or other glandular disorder?
G. Arthritis, bursitis, sciatica, gout, recurrent back pain, or any disorder of the back, spine, muscles, bones, or joints?
H. Disorder of the eyes, ears, nose, or throat?
I. Cyst, tumor, cancer, or blood disorder?
J. Disorder of the skin, lymph system, or breasts?
K. Any physical deformity or defect?
L. Any disease not previously covered (other than minor childhood diseases)?
M. Have you or your husband ever had marital problems? Have either of you ever seen a psychologist or other mental health counselor? (If so, when and why)
N. Do you want more children of your own? (If so, how many, and when would you like more?)
O. Do you own a major credit card?
P. Have you ever had an abortion?
Q. Had a check-up, consultation, illness, or surgery?
R. Been treated or evaluated at a hospital, clinic or other medical facility?
S. Had an EKG, x-ray, or other diagnostic test?
T. Been advised to have any medical test or surgery and not followed such advice?
U. Do you (or your husband) smoke cigarettes or have done so within the past year?
Only non-smokers are permitted into the SMI program. If you smoke, please do not continue to complete the application.
V. Did you smoke while you were pregnant?
W. Are you currently taking any prescribed medicines?
X. Have you ever been advised to limit your use of alcohol or other addictive substances?
Y. Do you drink coffee?
Z. Have you ever been treated for or told to seek treatment because of alcohol or drug abuse, or any other chemical dependency?
AA. Do you exercise? If so, how and how often?
BB. Has any member of your immediate family ever had diabeters, cancer, stroke, high blood pressure or any type of heart disease? If so, identify each person, condition, and age or age at death.
CC. Have either of your parents passed away? If so, please list the cause and date of death on the next page.
DD. Have you, your husband, or any of your children been charged with or convicted of any crime (other than minor traffic offenses)?
EE-1. Do you have or are you covered by medical insurance?
EE-2. Does your insurance cover pregnancy?
FF-1. Are you currently using any type of birth control, or have you ever had a tubal ligation, or has your husband had a vasectomy?
FF-2. Have you ever used Depo-Provera or been on The Pill in the past year?
GG. Have you (or your husband, if married) ever declared bankruptcy?
HH. Have you ever applied to any other surrogate program, or do you now have an application pending with any other program?
II. Which best describes your cycles:
JJ. Have you ever used marijuana, cocaine, crank, or any other controlled substance? If so, when was the last time, how often did you use it, and what drug did you use?
KK. If you were to be given a urine screen today, would you test negative? If not, what would you test positive for?
LL. Do you have any children who have ever lived with someone other than you? If so, please state who they are, where they lived and when, and the reason that they lived elsewhere.
To continue the application press the "Next" button below.