Medical Screening Questionnaire "*" indicates required fields This questionnaire is designed to help our surrogates successfully complete the clinic’s medical screening process. You must answer truthfully below; otherwise, your medical screening may be delayed or canceled. Please remember: Avoid casual conversations with the medical screening clinic staff. Your past personal matters unrelated to surrogacy should not be disclosed. Please answer the following questions truthfully so we can better prepare you for your clinical medical screening. BASIC INFORMATIONName* First Last Phone*Email* Birthdate* MM slash DD slash YYYY Age* Do you smoke? Yes No If Yes, what kind? (Cigarettes/Marijuana/Vape/Edible)* Does your partner smoke?* Yes No Do you drink alcohol?* Yes No If Yes, please specify:* Do you take any medications?* Yes No If Yes, please list:* Have you taken any weight loss medications within the last four months?* Yes No If Yes, please list:* Do you currently have an IUD, Nexplanon, or are you on the Depo shot?* Yes No Have you ever had an IUD or Nexplanon?* Yes No If Yes, when was it removed? How long did you have it in place? Were any of these discontinued?* Have you ever been convicted of a crime such as a DUI?* Yes No If Yes, please specify:* Have you ever been prescribed or taken medications for depression or anxiety?* Yes No If Yes, please specify:* Have you gotten any tattoos or piercings within the last year?* Yes No If Yes, where?* Are you currently breastfeeding?* Yes No Are you on any government aid?* Yes No If Yes, what kind?* Are there any past events we should be aware of?* Yes No If Yes, please provide details?Do you have work authorization?* Yes No Do you have an irregular menstrual cycle?* Yes No Are you taking thyroid medication?* Yes No CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.
