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SURROGACY QUESTIONNAIRE (SURROGATE PARENT/S)

1. Documents Required

1.1 Identity Book of all the parties: Yes
1.2 Proof of Address of all the parties: Yes
1.3 Birth Certificates of the children born to the surrogate: Yes
1.4 Marriage certificate of all parties: Yes
1.5 Surrogate Mother salary slip: Yes
1.6 Surrogate husband/partner salary slip: Yes

Note - You will be required to provide your fingerprints for a criminal database search, to see if you have been convicted of a criminal offence within South Africa. We will also obtain medical reports from your treating doctor, together with a psychologist’s report of both you and your partner, if you have one.

2. Surrogate Mother's Details

Surrogate Mother
First name:
Surname:
Identity Number:
Residential Address:
Contact No.:
Email Address:
Work/Job Title:
Employer’s Details:
2.1 Racial group
2.1.1 White
2.1.2 Black
2.1.3 Coloured
2.1.4 Indian
2.1.5 Oriental
2.1.6 Other: 
2.2. Do you have a preference as to whom you don’t want to be a surrogate for?

3. Marital Status:

3.1 Marital status is:

3.1.1 Unmarried
3.1.1.1 Are you currently in a monogamous relationship? Yes No
3.1.1.2 How many sexual partners have you had in the past 6 months? (number)
3.1.2 Married
3.1.2.1 We were married on: (date)
3.1.2.2 We have been married for: (years)
3.1.3 Civil Union/ De Facto Marriage / Life Partnership
3.1.3.1 We have been together for: (years)

3.2 Partner’s details are:
Surrogate Husband/ Partner / Life Partner
First name:
Surname:
Identity Number:
Residential Address:
Contact No.:
Email Address:
Work/Job Title:
Employer’s Details:
3.3 My husband/ partner is fully supportive of my decision to be a surrogate:

3.3.1 Yes
3.3.2 No

4. Domicile:

4.1 I/We are South African citizens:

4.1.1. Yes
4.1.2. No, our nationality is:

4.1.2.1. Commissioning Partner 1:
4.1.2.2. Commissioning Partner 2:

4.2 I/We currently reside in South Africa:

4.2.1. Yes
4.2.2. No, we live in:

5. Employment:

5.1 Are you currently working:

5.1.1 No
5.1.2. Yes
5.1.2.1. What is your job title:
5.1.2.2. How long have you worked for your current employer:
5.1.2.3. What is your gross monthly income:
5.1.2.4 Do you earn any additional income (commission):

5.2 Is your partner/spouse currently working:

5.2.1 No
5.2.2. Yes
5.2.2.1. What is your job title:
5.2.2.2. How long have you worked for your current employer:
5.2.2.3. What is your gross monthly income:
5.2.2.4 Do you earn any additional income (commission):

5. Employment:

6.1 I/We have children:

6.1.1 No
6.1.2. Yes, their details are:

6.1.2.1 Child 1:
6.1.2.1.1. Name:
6.1.2.1.2. Date of Birth:
6.1.2.1.3. Delivery Date:
6.1.2.1.4. Birth Weight:
6.1.2.1.5. Length of pregnancy:
6.1.2.1.6. Single/ Multiple:
6.1.2.1.7. Vaginal/ C-Section:
6.1.2.1.8. Pregnancy:
6.1.2.1.9. Any complications:

6.1.2.2 Child 2:

6.1.2.2.1. Name:
6.1.2.2.2. Date of Birth:
6.1.2.2.3. Delivery Date:
6.1.2.2.4. Birth Weight:
6.1.2.2.5. Length of pregnancy:
6.1.2.2.6. Single/ Multiple:
6.1.2.2.7. Vaginal/ C-Section:

6.1.2.3 Child 3:

6.1.2.3.1. Name:
6.1.2.3.2. Date of Birth:
6.1.2.3.3. Delivery Date:
6.1.2.3.4. Birth Weight:
6.1.2.3.5. Length of pregnancy:
6.1.2.3.6. Single/ Multiple:
6.1.2.3.7. Vaginal/ C-Section:

7. Previous Surrogacy’s:

7.1 I have been a surrogate before:

7.1.1 No
7.1.2 Yes, I have been a surrogate before. I gave birth on:

8. Preferred Method of Delivery:

8.1 Natural
8.2 Caesarean Section (C-Section);
8.3 Either, the attending doctor and Commissioning Parents can decide.

9. Abortion

9.1 My feelings on abortion are:

9.1.1 No, I will never have an abortion;
9.1.2 Yes Yes, I will have an abortion should the Commissioning Parents and attending doctor think that the situation/ pregnancy requires it and it is in terms of the Choice of Termination of Pregnancy Act.

10. Number of Treatment Cycles and Embryo Transfers:

10.1 I am willing to undergo the following number of treatment cycles until we are successful:

10.1.1 one
10.1.2 two
10.1.3 three
10.1.4 As many as it takes to achieve a successful pregnancy within the eighteen (18) month time limit.

10.2 I am willing to have the following number of embryos transferred per cycle:

10.2.1 one
10.2.2 two, and I accept the risk of a multiple pregnancy;
10.2.3 three, and I accept the risk of a multiple pregnancy.

*Note – there is always a risk of a multiple pregnancy even with one (1) embryo being transferred.

11. Religion and religious preferences:

11.1 What is your current religious affiliation?
11.2 Do you have any religious preference for the commissioning parents?
11.2.1 No:
11.2.2 Yes (specify what)

12. Lifestyle:

12.1 What is your current weight?
12.2 What is your current height?
12.3 Do you smoke?

12.3.1 No;
12.3.2 Yes;
12.3.2.1 How many cigarettes per day do you smoke:
12.3.2.2 How long have you been smoking for?
12.3.2.3 Are you able and willing to stop immediately and submit for testing if necessary?

Yes;
No;

12.4 Does your current partner smoke?

12.4.1 No;
12.4.2 Yes;

12.4.2.1 How often are you exposed to cigarette smoke

12.5 Do you drink alcohol?

12.5.1 No;
12.5.2 Yes, how many units (1 glass = 1 unit) per day do you drink;
12.5.3 Are you able and willing to stop immediately and submit for testing if necessary?
12.5.3.1 Yes;
12.5.3.2 No;

12.6 Does your current partner drink?

12.6.1 No;
12.6.2 Yes, how many units (1 glass = 1 unit) per day does your partner drink per day:

12.7 Have you ever been advised to limit your use of alcohol or any drugs? If yes (limit alcohol or drugs), please explain:

12.7.1 No;
12.7.2 Yes: please explain

12.8 Have you ever had any problems with alcoholism or drug abuse?

12.8.1 No;
12.8.2 Yes; please explain;

12.9 Do you follow any specific diet or have any special dietary habits?

12.9.1 No;
12.9.2 Yes;(specify what)

12.10 Do you exercise?

12.10.1 No;
12.10.2 Yes;(specify what and how often)

12.11 How often are you exposed to strong, prolonged heat sources such as saunas, hot tubs, steam rooms?

12.11.1 Days per week:
12.11.2 Length of time per session:

13. Criminal Record:

13.1 I/We have NOT been convicted of a criminal offence;
13.2 I/We HAVE been convicted of a criminal offence. Details of offence:
Date:
Description:
Date:
Description:

14. Medical Information:

14.1 Blood type:

14.2 Are you currently on any contraceptives?

14.2.1 No;
14.2.2 Yes; (specify what)

14.3 Do you currently have any allergies?

14.3.1 No;
14.3.2 Yes; (specify what)

14.4 Do you use prescription drugs?

14.4.1 No;
14.4.2 Yes; (specify what)

14.5 Do you use non-prescription drugs?

14.5.1 No;
14.5.2 Yes;(specify what)

14.6 Do you use any recreational drugs (Marijuana, cocaine, ecstasy, Valium, etc.)?

14.6.1 No;
14.6.2 Yes; (specify what)

14.7 In the past 5 years, have you had sexual contact with anyone in high-risk groups for HIV/ AIDS? These include intravenous drug users, recipients of blood products, transfusions, and sexually active persons with multiple partners?

14.7.1 No;
14.7.2 Yes; (specify what)

14.8 Are you at risk for HIV/AIDS?

14.8.1 No;
14.8.2 Yes; (specify what)

14.9 To your knowledge, have any of your sexual partners in the last 5 years been sexually active with anyone in the high- risk group for HIV/AIDS?

14.9.1 No;
14.9.2 Yes; (specify what)

14.10 Do you currently have any medical problems or conditions?

14.10.1 No;
14.10.2 Yes; (specify what)

15. Reason for surrogacy?

15.1 The reasons for wanting to be a surrogate are because:

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