For Prospective Parents   About Our Surrogate Program   Anticipated Costs   Legal Facts   Financial Assistance Program   Sample Surrogate Profile   Parent Application   View Surrogate Profiles For Prospective Surrogates Sample Surrogate Profile   Applicant ID #    000067   Personal Information: Age:   30     State of Birth:   Country of Birth: CA     USA     Partner Information: Marital Status/History: Married   Employment History: Current Occupation: Special Educator Years at current employment:   2       If less than 2 years, provide:     Previous Occupation:   Current/Owner Years at previous employment:   6       Current hours worked / week:   20         General Information: Would you require day care/baby sitting to attend any appointments associated with the ovum donation/surrogacy procedure?  Yes       Do you own a car? Yes If no, do you have alternate reliable transportation?   Yes         Personal Profile: Religion: Christian Practicing?   Yes       Blood type:   B positive       Height:   5 Ft   2 In Weight:   110 Pounds BMI:   20.1   Personal Questions: How is your overall health?: Excellent (medical/dental/fertility)   Have you ever been diagnosed and/or treated for Cancer? No If yes, please explain:   Have you ever been diagnosed and/or treated for Asherman's Syndrome? No If yes, please explain:   Are you currently a smoker? No If you smoke, how much?   Packs/Day If you have quit, what was the approximate date?   0000       Do you drink alcohol? No If yes, how much?   /Week       Do you or have you used any non-prescription drugs? No If yes, please describe:   Do you or have you used any prescription drugs? Yes If yes, please describe: birth control, fertility medication while I was a donor or surrogate   Do you or have you used any illegal drugs? No If yes, please describe:   Have you ever had a drug or alcohol abuse problem? No If yes, please describe:   Are you currently suffering from and/or been     diagnosed or treated for Anorexia/Bulimia? No If yes, please describe:   Have you ever been under the care of a Psychiatrist? No If yes, please describe:   Have you ever been under the care of a Psychologist/Family Therapist? Yes If yes, please describe: Psychological testing for Ovum Donation and Surrogacy   Have you ever had any psychiatric hospitalizations? No If yes, please describe:   Have you ever been arrested or convicted of a crime? No If yes, please describe:   Have you ever had surgery of any type?     (including cosmetic surgery) Yes If yes, please describe: C-Section in 1995 and Breast Implants in 2001   Have you ever had a blood transfusion? No If yes, please describe:   Have you ever been diagnosed with an STD? No If yes, please describe:   Do you have any tattoos? Yes Approximate date of your last tattoo?   2000     Fertility Profile: Age when you first started your menstrual cycle: 16 Are your cycles regular?   Yes How many days between your monthly cycle?   28 Date of last cycle:   2006 What is the birth control you are currently using?   vasectomy How many children do you have living with you?   3 What are their ages?   16,10, 8       How many pregnancies have you had? 4 How many resulted in a live birth? 2       Did any pregnancies result in a miscarriage? Yes If yes, how many and please explain the details: two surrogacy pregancies, miscarried (conceived via donor egg)   Did you experience any complications during your pregnancies     or during delivery? Yes If yes, please explain: only my first daughter was breech and was delivered c-section (Both your own personal pregnancy and any previous surrogacy)   Did any birth(s) result in a Caesarian Section? Yes If yes, please explain: see above   Have you had any trouble becoming pregnant?     (taking longer than six months) No If yes, please explain:   Have your parents or siblings experienced difficulties     becoming pregnant? (conceiving) No If yes, please explain:   Was your mother administered diethylstilbestrol (DES) or any     other prescription drug while she was pregnant with you? No If yes, please list the known prescriptions and the reason it was prescribed:     Delivery History:   Delivery Date Birth Weight Length of Labor Single/Multiple Vaginal/C-Section 1 1995 5.5 lbs 0 hrs Single C-Section 2 1998 6.5 lbs 2.5 hrs Single Vaginal 3 0000 lbs hrs 4 0000 lbs hrs 5 0000 lbs hrs 6 0000 lbs hrs   Character Profile: How would you describe your personality?   Outgoing, love to be around people (Quiet, Energetic, Artistic, Etc.)   Describe you special interests, hobbies, talents: Interior design, re-finishing furniture, reading   Do you have any special goals you are working towards?   Obtain Masters degree in special education (personal or professional)       Do you participate in any sports or recreational activities? Yes If yes, please describe: just work out at the gym, keep myself fit to keep up with my children's activities     Educational Profile: Are you currently a student? Yes What is your current GPA?   4.0 What is your current Major?   special education       Highest level of education completed:   College Degree Degree/Diploma/Certification:   degree       What are your ultimate career goals or desires? Masters degree in Special ed       Photographs:   Site Design by IV Interactive  ©2008 A Center for Coastal Conceptions. All Rights Reserved.