Family Physician Health History Questionnaire

For women thinking about becoming a gestational carrier. Please answer the following questions as accurately as possible based on your medical records and clinical history. All information is confidential.

Purpose

Your patient is inquiring about becoming a gestational surrogate with True Match Surrogacy Ltd. This form is intended to provide general medical information regarding her overall health, pregnancy history, and any medical conditions that may affect a future pregnancy.

General Medical History

Weight (indicate kg or lbs)

Does the patient have (currently or previously) any of the following?

	Yes	No
High blood pressure
Diabetes (Type 1, Type 2, Gestational)
Thyroid disorder
Heart disease
Kidney disease
Asthma or lung disease
Autoimmune disorder
Blood clotting disorder
Seizure disorder
Mental health diagnosis
Substance use disorder
Infectious disease concerns
Any condition that may complicate pregnancy

If yes to any above, please explain:

Has the patient had any major surgeries affecting pregnancy / delivery.

Yes

If yes, please list procedures and dates:

Obstetrical & Gynecological History

Number of Pregnancies

Has the patient experienced any of the following during pregnancy?

Medications & Lifestyle

Does the patient currently use or have a history within the last 5 years of:

Mental Health & Stability

Physician Assessment

In your professional opinion, is this patient generally medically appropriate to pursue a future pregnancy/surrogacy?

Yes

Further assessment recommended

Physician Declaration

Physician Signature

Sign Here

College Registration Number:

Clinic Contact Information:

I certify that the information provided above is accurate to the best of my knowledge based on my care of this patient and available medical records.

I consent to have this website store my submitted information so they can respond to my inquiry

	Yes	No
Preeclampsia
Gestational diabetes
Preterm labor
Placental complications
Postpartum hemorrhage
Severe postpartum depression
Recurrent pregnancy loss
Any high-risk pregnancy complications

	Yes	No
Tobacco (Nicotine)
Recreational drugs
Excessive alcohol use

	Yes	No
Untreated mental health concerns
Cognitive impairment affecting consent
Concerns regarding ability to comply with medical care