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SM0440617

Profile

GENERAL DETAILS

  1. Age: 27                                                           Year of Birth: 1991
  2. Husband Age: 30
  3. Native: Arakonam, Settled in Chennai       
  4. Height: 5.2ft       
  5. Weight: 42kg       
  6. Education: Higher Secondary                           From Year to         Year
  7. Religion: Hindu     
  8. Veg/Non-Veg: Non-veg
  9. Nationality: Indian

10.   Identity Proof: Aadhar card, kid’s birth certificate, photo  

11.   Blood Group: O+   

12.   Languages known: tamil

 

Physical Appearance

  1. Physical Build                              Medium
  2. Skin Complexion                           Wheatish/Slightly Dark
  3. Eye Color: Black                               
  4. Hair Color: Black                              
  5. Natural Texture of Hair:               Thick

           

 

Marital Status

Married              

 

MARRIED

  1. Date of Marriage: 28/08/2007                
  2. Has your husband accompanied you for the interview? Yes        
  3. If not, reason for the same:   

 

  1. Have you been married more than once?         No
  2. Does your husband agree?                              Yes
  3. Do you have a marriage certificate or any proof of marriage?

No

If yes, Proof Type                        ID Number

PERSONAL CHARACTER

  1. Please describe your personality and character? Always think good to others
  2. What do you like most about yourself? Straight forward
  3. What are your hobbies and interest? Watching tv
  4. What is the work that you would love to do most? All house hold works
  5. How do you emotionally feel about being an egg donor? Feeling happy to help
  6. What was your most interesting subject in your education? Tamil
  7. How attached are your towards your family? Very attached- father

 

HABITS

  1. Do you use tobacco or do you smoke?             No
  2. Do you consume alcohol?                                No
  3. Does your husband use tobacco?                     No
  4. Does your husband consume alcohol?             No

 

PREGNANCIES

  1. Have you ever had a fertility problem?              No
  2. If YES, please give details

 

  1. Have you had a multiple birth?                         No
  2. How many children do you have?

Male

2

Female

 

           

  1. Have you ever suffered a miscarriage?             No
  2. Have you ever any ectopic pregnancies?          No
  3. Have you suffered a stillbirth?                          No
  4. Have you suffered from Post-natal Depression?   No

If yes, please provide details of the same.

         

  1. Have you undergone surrogacy earlier?            No
  2. Have you taken up egg donation earlier?          No

If yes, please provide details of the same.

 

  1. Please give details of deliveries:

 

1

2

3

4

Normal/

C-Section

Normal

C-section

 

 

Dates of Birth

24/08/2008

13/07/2010

 

 

Weight

3.500kg

3.500kg

 

 

Was pregnancies full term?

Yes

Yes

 

 

Did any of your children have a medical problem at birth

No

No

 

 

Do any of your children have health problems? (Physical or Psychological)

No

No

 

 

Blood Group

 

 

 

 

 

FAMILY PLANNING

  1. Have you done family planning?                       Yes
  2. Present contraception method?                        Yes

Describe -

  1. Has your husband done family planning?          No
  2. If answer to the above two questions is No, do you understand the importance of abstaining from Intercourse at the time of ovulation?

Yes

  1. Have you completed your family?                     Yes

 

MEDICAL

  1. Have you gained or lost over 10 kilos in the past six months?

No

  1. If yes, please give details
  2. Have you been immunized?                             Yes
  3. Have you ever had any psychiatric problems?   No
  4. Are you presently taking any medication?         No
  5. Do you have any diseases, such as, diabetes/epilepsy, etc.

No

7.     Are you known allergic to any particular drug or substance/food?

No              If yes, specify

8.     How long is an average monthly cycle for you?  30 days

9.     How long do your periods last?                          3 Days

10. LMP: 11/06/2017

11. Do you wear glasses?                                      No

If yes, what is the type and power?

 

FAMILY MEDICAL HISTORY:

  1. Does anyone in your family have any genetic diseases, such as, diabetes, epilepsy or any heart problem?    No
  2. Does anyone in your family have twin children? No
  3. Is there some medical condition in your family that you might consider would pass on genetically?                              No

MEDICAL (PARTNER):

1.     Is your husband suffering from disease that is transmittable orally, such as, TB, etc.                                                            No

2.     Is your husband suffering from any Sexually Transmittable Disease?

No

3.     Is your husband suffering from any psychiatric problem or any mental issue?                                                              No

 

SUPPORT

  1. Do you have someone to offer practical and emotional support?

Yes

Name and relation: Husband

  1. Is your family aware of your intention to become a surrogate mother/egg donor?

Yes

 

Convenience

  1. If chosen, how far are you prepared to travel to a clinic?        20kms                              
  2. Are you willing to travel to any other city other than your present residence?                                                      No

 

EMPLOYMENT:

  1. Are you currently employed?                            No 
  2. Occupation/Nature of work:                                     
  3. Previous occupation: Abacus teacher                        
  4. If YES, how many hours a day/week?                                          
  5. Would your employer allow you time off to attend hospital/clinic appointments for treatment etc.?                      Yes           No
  6. If you are employed or have been employed, what is the pay that you had been receiving? Rs. 4,500/-
  7. Is your spouse currently employed?                  Yes
  8. Nature of work/occupation of your spouse: Car Driver

 

Family details

Please write a short statement about you, your family, and most importantly your reasons for wanting to be a surrogate mother/egg-donor. Please also mention other information you wish to communicate to the intended parents.

Candidate’s father passed away and mother is a housewife. Candidate has one elder brother and he is working in Electricity Board. Candidate wants to be an egg donor and surrogate mother due to financial problem. Candidate arrange married her husband

 

LEGAL COUNSELLING

Are you being forced into taking up the egg donation/surrogacy arrangement by anyone? No

Are you willing to be a surrogate mother/egg donor only out of your Free Will?

Yes          

Do you or your spouse have any criminal convictions, or criminal proceedings pending?                                     No

EGG DONOR

1.               Do you know that you have to complete your family before you can get enrolled with Giftlife Egg Donor Program?

Yes          

2.               Do you know that you have a risk of becoming infertile, if selected?

Yes          

3.                Are you informed of the following:

(a)            The basic process of Egg Donation        Yes

(b)             The gametes (eggs) that would be retrieved from you by ART by stimulation with hormonal drugs would be the sole property of the childless couple.                                                           Yes

(c)             You would have no control over the gametes that have been retrieved from you or the child that may be created/born out of such gametes?

Yes

(d)            You still remain an anonymous Egg Donor, shall have no knowledge of who would be using your gametes?                  Yes

(e)            You would not be making any attempt to identify the childless couple whom you are helping.                                     Yes

4.               Do you have any doubts/queries?

 

SURROGATE:

Do you know

1.               That you would be carrying a child for another couple?

Yes

2.               That you will have no rights over the child that would be born to you?

Yes

3.                That yourself and your family would be paid a compensation for the efforts for helping the childless couple?

Yes

4.               That you would be required to sign a surrogacy agreement that would govern your conduct before, during and after the surrogacy arrangements?

Yes

5.               You cannot claim any rights over the child that may be born out of this arrangement during or after the surrogacy arrangement?

Yes

6.               You would take up all medical risks that you may be exposed to in the process and sign your consent in the consent forms for the same?

Yes

7.               You would not hold GIFTLIFE and Indian Surrogacy Law Centre for any medical risks, known or unknown and you will absolve ISLC for all risks, including medical that you may incur?

Yes

 

COMPENSATION:

  1. What is your monthly income?
  2. What is the monthly income of your family? Rs. 14,000/-
  3. Do you or anyone in your family own any movable or immovable assets? No
  4. If you were selected, how much compensation according to you would be appropriate for your services? Rs.40,000 for ED and Rs.4 lakhs for SM

 

  1. What would you do with the compensation that would get out of this effort? To buy vehicle on own and to repay loans

 

  1. Something that you would like to communicate to childless couple that you would help in the process?

 

 

 

 

Comments by interviewer