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  1. Age:                       24 years                 Year of Birth: 25.05.1992
  2. Husband Age:         26 years
  3. Native:                    Chennai
  4. Height:                    152 cms
  5. Weight:                   41 kgs,
  6. Education:              Msc.(Family Research) Discontinued      From Year to       Year
  7. Religion:                  Hindu
  8. Veg/Non-Veg:         Non Veg.
  9. Nationality:              Indian

10.   Identity Proof: 

11.   Blood Group:           O positive

12.   Languages known: Tamil, English


Physical Appearance

  1. Physical Build                              slim              Medium



  1. Skin Complexion                                                        

Slightly Dark      

  1. Eye Color:                                   Black
  2. Hair Color:                            
  3. Natural Texture of Hair:               Thin                            



Marital Status

Married              Divorced             Single                 Separated



  1. Date of Marriage:              05.05.2014
  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? 1817/2014

Yes                    No

If yes, Proof Type                        ID Number



  1. Please describe your personality and character? She is jovial person


  1. What do you like most about yourself? She is calm.


  1. What are your hobbies and interest? Reading newspapers


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


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


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


  1. How attached are your towards your family?


Her Mother and his grand mother



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



  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?






  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:












Dates of Birth






2.9 kgs.




Was pregnancies full term?





Did any of your children have a medical problem at birth





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





Blood Group







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

Describe -     Condoms

  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?


  1. Have you completed your family?                     No



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


If yes, please give details

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


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

No                  If yes, specify

7.     How long is an average monthly cycle for you?  28                days

8.     How long do your periods last?                5 days                    Days

9.     What the next expected date of your menstruation for scheduling medical screening?  21.07.2017

10. Do you wear glasses?                                                          No

If yes, what is the type and power?



  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




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?


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



  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?

Yes                    No



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



  1. Are you currently employed?                                                No 
  2. Occupation/Nature of work:                                     
  3. Previous occupation:                            
  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?
  7. Is your spouse currently employed?                  Yes                    CTS CAB MAINTENANCE
  8. Nature of work/occupation of your spouse:


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.

She has two sisters.  Both are married


He has one brother and one sister.  Her mother and grandmother will help during the process.  Studying.



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?


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


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

Yes                    No

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

Yes                    No

3.                Are you informed of the following:

(a)            The basic process of Egg Donation        Yes                    No

(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                    No

(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                    No

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

(e)            You would not be making any attempt to identify the childless couple whom you are helping.                                     Yes                    No

4.               Do you have any doubts/queries?






Do you know

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


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


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


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

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


5.               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?


6.               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?




  1. What is your monthly income?  : Rs.15,000/-
  2. What is the monthly income of your family?
  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 lakhs


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

For family

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

You are happy in helping the childless couple




Comments by interviewer


She is very much willing to take up the surrogacy arrangements.  She wants to be in her house in Ennore at the initial stage.  She is likely to move nearby the hospital  and she will reside in a rented house till the birth of the child and for subsequent period.