This survey helps Circle Surrogacy pre-screen candidates. Please take the time to ensure complete and correct responses.

* 1. Are you under the age of 21 or over the age of 40?

No  Yes

* 2. Have you used Tobacco within the last year?

No  Yes

* 3. Have you used antidepressants in the last year?

No  Yes

* 4. Is your BMI over 32? (You can check your BMI at The CDC Website)

No  Yes

* 5. Do you have any history of illegal drug use or alcohol abuse?

No  Yes

* 6. Can we verify that your income is above the poverty level in your county?

No  Yes

* 7. Have you had two or more miscarriages?

No  Yes

* 8. Have you given birth before?

No  Yes

* 9. Have you ever had a C-Section? If so, how many have you had?

I've never had a C-Section.  Once  Twice  Three or more times

* 10. Are you currently receiving any government financial assistance? (this would include; food stamps, public housing, welfare subsidies)

No  Yes