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SMC0150417

Profile

GENERAL DETAILS

  1. Age: 30                                                                       Year of Birth:07.01.1986
  2. Husband’s Age:35
  3. Native: Pollachi
  4. Height:150 Cm
  5. Weight: 46
  6. Education: 10th                                    From   Year to            Year
  7. Religion: Hindu
  8. Veg/Non-Veg: both
  9. Nationality: Indian

10.    Identity Proof: Aadhar ID

11.    Blood Group: B Possitive

12.    Languages known: Tamil

 

Physical Appearance

  1. Physical Build                                     Medium

           

  1. Skin Complexion                                Slightly Dark
  2. Eye Color: Brown                               
  3. Hair Color: Black                                
  4. Natural Texture of Hair:                      Thin           

                       

 

Marital Status

Married                   

 

MARRIED

  1. Date of Marriage: 26.05.2011            
  2. Has your husband accompanied you for the interview? Yes        

If not, reason for the same:

 

  1. Have you been married more than once?      Yes            
  2. Does your husband agree?                            Yes            
  3. Do you have a marriage certificate or any proof of marriage?

Yes             No

If yes, Proof Type                               ID Number

 

PERSONAL CHARACTER

  1. Please describe your personality and character?

Jolly type

  1. What do you like most about yourself?

Helping tendency

  1. What are your hobbies and interest?

Watching TV and hearing songs

  1. What is the work that you would love to do most?

Cooking

  1. How do you emotionally feel about being an egg donor?

Feel happy

  1. What was your most interesting subject in your education?

Tamil

  1. How attached are your towards your family?

Closely attached

 

HABITS

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

 

PREGNANCIES

  1. Have you ever had a fertility problem?                       No

If YES, please give details

 

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

Male

 

Female

1

           

  1. Have you ever suffered a miscarriage?                     Yes 3 years before           
  2. Have you undergone MTP?                                       No
  3. Have you ever any ectopic pregnancies?                  No
  4. Have you suffered a stillbirth?                                    No
  5. 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

C

 

 

 

Dates of Birth

31.03.2012

 

 

 

Weight

2.900

 

 

 

Was pregnancies full term?

Yes

 

 

 

Did any of your children have a medical problem at birth

No

 

 

 

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

No

 

 

 

 

 

FAMILY PLANNING

  1. Have you done family planning?                                                        No  
  2. Present contraception method?                                 Yes             No

Describe - No

  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?                                  28 days

9.     How long do your periods last?                                                           5 Days

10.  LMP: 29.03.2017

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             No

Name and relation:

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

                        No

Convenience

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

EMPLOYMENT:

  1. Are you currently employed?                          Yes            
  2. Occupation/Nature of work:    Working as a labour in spinning mill  
  3. Previous occupation: -                      
  4. If YES, how many hours a day/week? 8 Hours                                            
  5. Would your employer allow you time off to attend hospital/clinic appointments for treatment etc.?                                    Yes            
  6. If you are employed or have been employed, what is the pay that you had been receiving? Rs. 275 Per day
  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.

To settle debts. I wish to communicate to the intended parents to take care of the child well.

 

LEGAL COUNSELLING

Are you being forced into taking up the egg donation/surrogacy arrangement by anyone? Yes             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?                                    Yes            

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 upall 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?  5,000/-
  2. What is the monthly income of your family? 13,,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. 4,00,000 to 4,50,000

  1. What would you do with the compensation that would get out of this effort?

To Settle debts

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

Will co operate through out the process.

 

 

 

Comments by interviewer