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  1. Age: 27                                                           Year of Birth: 1990
  2. Husband Age: 30
  3. Native: Chennai       
  4. Height: 4.7 ft       
  5. Weight: 62 kg       
  6. Education: Middle school                       From Year 2010 to 2012 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: B+   

12.   Languages known: Tamil


Physical Appearance

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



Marital Status




  1. Date of Marriage: 11/07/2006                
  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 – Love Marriage

If yes, Proof Type                        ID Number


  1. Please describe your personality and character? Adjustable, Short temper at times
  2. What do you like most about yourself? Silent and calmness
  3. What are your hobbies and interest? Watching tv, listening to songs
  4. What is the work that you would love to do most? All types of house hold works
  5. How do you emotionally feel about being a Surrogate Mother? Feeling happy to help and get benefit out of it
  6. What was your most interesting subject in your education? Maths
  7. How attached are your towards your family? Very attached – Sister’s wife



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



  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?             Yes
  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










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?                       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?


  1. Have you completed your family?                     Yes



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


  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.


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: 05/09/2017

11. 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?


Name and relation: Husband

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

No – Love marriage



  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



  1. Are you currently employed?                            Yes – Working in Arun Ice Cream as daily labourer
  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? Rs. 8,000
  7. Is your spouse currently employed?                  Yes
  8. Nature of work/occupation of your spouse: AC Mechanic


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 died in an accident and candidate has not seen her mother and she has been deserted from family. Candidate is the only daughter in her family. Candidate wants to be a surrogate mother due to financial problem. Candidate love married her husband and living separately from parents.



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. What is your monthly income? Rs. 8,000/-
  2. What is the monthly income of your family? Rs. 18,000/-
  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/- for SM
  5. What would you do with the compensation that would get out of this effort? To repay loans


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





Comments by interviewer

Candidate appeared for interview with her husband. Candidate understands the process very well.