Address: _____________________________________________Home: (_____)________________________

________________________________________________________Work: (_____)________________________

________________________________________________________Cell: (_____)__________________________

E-mail Address: _____________________________________Date of Birth:_____________

Occupation:__________________________________________Blood Type: _____(+) or (-)

Are you a Florida Resident? _____ Are you a U.S. Citizen? _____ Do you have a Green Card? _____

Do you have Health Insurance:___________________Name/#: __________________________________

Previous Egg Donor: YES_______ NO_______ Previous Surrogate: YES_______ NO______

_________________________________________________________________________________________________

* PLEASE ENCLOSE A RECENT PHOTO of yourself and any children you may have. We suggest a photo of which you have duplicates, as we cannot guarantee its return.

* Are you interested in being: _____________ a surrogate mother or _____________ an egg donor

* On a separate sheet of paper, please explain why you wish to be a Surrogate Mother or an Egg Donor

Age: _________ Date of Birth: _________________ Height: ______________Weight:______________

Eye Color:______________________Natural Hair Color: _______________________________________

Skin Color(Check all that apply) : _____Fair _____Medium _____Olive _____Light Brown ______Dark Brown _____Ebony _____Freckled _____Rosy

Birthmarks: ________________________________________________________________________________________

Do you wear corrective lenses? ___________For What Problem? ____________________________

Do you wear corrective aids? ______________For What Problem?________________________________

If Yes, please explain: ____________________________________________________ At What Age: _______

Race: __________________________________Ethnic Origin:_____________________________________

Mother: ________________________________ Father:_____________________________________________

What physical activities do you engage in?______________________________________________________

Have you excelled in any physical activities? __________ Please explain: ________________________

___________________________________________________________________________________________________

Please describe any musical abilities or talents: _________________________________________________

Please describe any skills or talents that you have (e.g. painting, writing, crafts): __________

_____________________________________________________________________________________________________

____________________________________________________________________________________________________

_____________ Currently in College, pursuing a degree in: ______________________________

_____________ Completed College, Degree in: _____________________________________________

_____________ Currently pursuing an advance degree in: _______________________________

_____________ Hold an advanced degree in: ______________________________________________

_____________ Technical and Specialized School, Certification or Degree in: __________

_____________ Any awards or any non-degree seeking classes taken: __________________

Please describe any problems or special circumstances having to do with your reproductive health (Failure to Conceive, Menstrual problems, Ovarian Cysts, etc.): ________________________

_________________________________________________________________________________________________

* Please indicate in the outcome column if it was a vaginal delivery, C-section, Ectopic, Miscarriage of Termination.

1. _______ ______________________________________________________________________

2. _______ _____________________________ _________________________________________

3. _______ ______________________________________________________________________

4. _______ ______________________________________________________________________

5. _______ ______________________________________________________________________

Birth Control Method Now used: _________________________ For How Long: ______________________

Do you smoke cigarettes? ______Yes _______ NoHow many packs per day? _________________

Do you drink Alcoholic beverages? _____Yes ______ No How often? __________________________

If yes, please explain: _______________________________________________________________________________

List prescription and non-prescription medications that you take regularly: _________________

_________________________________________________________________________________________________

Do you have any allergies? ______Yes ______No If Yes, please explain:___________________

_________________________________________________________________________________________________

Do you have any medical illnesses? (Asthma, Diabetes, Seizure Disorders, etc.): _____________

_________________________________________________________________________________________________

Describe your nutritional habits, likes and dislikes: ____________________________________________

_________________________________________________________________________________________________

1. _________________________________________________________________________________________________

2. _________________________________________________________________________________________________

3. _________________________________________________________________________________________________

Have you had a blood transfusion? ______________How long ago? _____________________________

Have you had major radiation or x-ray exposure? ________________________________________________

Please describe any other health issues that you have had:_____________________________________

_________________________________________________________________________________________________

Please read the following list of medical problems carefully and indicate which ones you or one of you relatives have had. Please consider each condition for each family members:

Medical Problems	You	Mother	Father	Siblings	Grand- parents	Other Family	Describe
C. Heart disease
1. From birth
2. Other
D. Hardening of arteries
E. High Blood Pressure
2. BLOOD
A. Anemia
B. Sickle-cell
C. Hemophilia Other Bleeding
D. Leukemia
E. HIV
F. Other Blood Disease
3. RESPIRATORY
A. Hayfever
B. Asthma
C. Emphysema
D. Tuberculosis
E. Lung Cancer
F. Pneumonia
G. Other Lung Disease
4. GASTRO-INTESTINAL
A. Ulcer of stomach or duodenum
B. Gallstone
C. Hepatitis A
D. Hepatitis B
E. Other Liver Disease
F. Colon Cancer
G. Ulcerative olitis
H. Crohn’s Disease
I. Cystic Fibrosis
J. Intestinal Cancer
K. any other cancer problems of digestive system
5. METABOLIC ENDOCRINE
A. Diabetes Mellitus
B. Hypoglycemia
C. Thyroid Cancer
D. Thyroid Disease
E. Goiter
F. Adrenal Dysfunction or Disorder
G. Hyperactivity
6. URINARY
A. Kidney Disease
B. Other disease of Urinary Tract
C. Rectal Disorder
7. GENITAL REPRODUCTION
A. Undescended Testicle
B. Hypospadiasis
C. Prostate
D. Uterine Fibroids
E. Ovarian Cancer
F. Cancer of Ovaries Cervix, uterus
8.NEUROLOGICAL
A. Migraines
B. Mental Retardation
C. Senility before age 50
D. Multiple sclerosis
E. Cerebral Palsy
F. Epilepsy
G. Hydrocephalus (water on brain)
H. Disorders of the Spinal Cord
I. Huntington’s chorea
J. Gaucher’s Disease
K. Wilson’s Disease
L. Other Disease of the Nervous System
9. MENTAL HEALTH
A. Schizophrenia
B. Manic Depressive
C. Other mental health problems requiring hospitalization
10. MUSCULAR, BONES & JOINTS
A. Muscular Dystrophy
B. Other chronic Muscle Disease
C. Lupus
D. Deformity of spine
E. Osteoporosis
F. Dwarfism
G. Hereditary Low Back Disease
H. Arthritis
I. Gout

What religion were you born into? ________________________________________________________________

What religion are you now? _______________________________________________________________________

Are you athiest? __________________________________ Agnostic: _____________________________________

Date of Birth:________________________ Social Security No.:_________________________

City:_______________________________ State:_________________ Zip:________________

I authorize Charlotte H. Danciu, P.A., to disclose the above-named individual’s health information as described below.

The type and amount of information to be disclosed is as follows: (Include dates where appropriate)

☐ ALL MEDICAL RECORDS DURING MY PREGNANCY INCLUDING BIRTH, DELIVERY AND POST-PARTUM

I understand that this information may include, when applicable, information relating to sexually transmitted disease, Human Immunodeficiency Virus (HIV infection, Acquired Immune Deficiency Syndrome or AIDS Related Complex) and any other communicable disease. It may also include information about behavioral or mental health services, and referral or treatment for alcohol and drug abuse (as permitted by 42 CFR Part 2).

This information may be disclosed to and used by the following person or organization.

I understand that I have the right to revoke this authorization at any time, I understand that if I revoke this authorization I must do so in writing and present my written revocation to The Law Offices of Charlotte H. Danciu, P.A. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy. Unless otherwise revoked, this authorization will expire one year from the signature date.

I understand that authorizing the disclosure of this health information is voluntary. I also understand that I may refuse to sign this authorization and that my refusal to sign will not effect my ability to obtain treatment, payment for services, or eligibility for benefits.

By signing this authorization, I understand that any disclosure of information carries with it the potential for an unauthorized redisclosure and the information may not be protected by federal privacy rules. I further understand I may request a copy of this signed authorization. A photostatic copy of this authorization shall serve in its stead.

Patient’s Name:_______________________ Social Sec. Number (if known):________________________

Date of Birth:_________________________ Health Rec.# (if known):_____________________________

1. I authorize the use or disclosure of the above named individual’s health information as described below:

2. The following individual or organization is authorized to make the disclosure:

3. The type and amount of information to be used or disclosed is as follows: (include dates where appropriate)

☐ other ___________________________________________________________________________

_________________________________________________________________________________

4. I understand that the information may included information relating to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services, and treatment for alcohol and drug abuse.

5. This information may be disclosed to and used by the following individual or organization:

6. I understand I have the right to revoke this authorization for my child at any time. I understand if I revoke this authorization I must do so in writing and present my written revocation to The Law Offices of Charlotte H. Danciu, P.A. I understand the revocation will not apply to information that has already been released in response to this authorization. I understand the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy. Unless otherwise revoked, this authorization will expire on the following date, event or condition: _______________. If I fail to specify an expiration date, event or condition, this authorization will expire in six months.

7. I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I need not sign this form in order to assure treatment. I understand I may inspect or copy the information to be used or disclosed, as provided CFR 164.524. I understand any disclosure of information carries with it the potential for an unauthorized re-disclosure and the information may not be protected by federal confidentiality rules. If I have questions about disclosure of my health information, I can contact an attorney or The Law Offices of Charlotte H. Danciu, P.A.

	AGE (if alive)	AGE (at death)	Medical problems or cause of death
Mother:
Father:
Brothers:


Sisters:


Maternal Grandmother:
Maternal Grandfather:
Paternal Grandmother:
Paternal Grandfather:
Children: