¿A quién puedo agradecer por haberte referido a MatchNest?
Friend or family member
Current MatchNest member
Social media (Instagram, Facebook, etc.)
Google or search engine
Podcast or blog
Event or workshop
Therapist or coach referral
Newsletter or email
Other
Si es otro, por favor especifica cómo te enteraste de nosotros.
Nombre completo
Fecha de nacimiento
Estatura
4'10"
4'11"
5'0"
5'1"
5'2"
5'3"
5'4"
5'5"
5'6"
5'7"
5'8"
5'9"
5'10"
5'11"
6'0"
6'1"
6'2"
6'3"
Peso
100–109 lbs
110–119 lbs
120–129 lbs
130–139 lbs
140–149 lbs
150–159 lbs
160–169 lbs
170–179 lbs
180–189 lbs
190–199 lbs
200–209 lbs
210–219 lbs
220–229 lbs
230–239 lbs
240–249 lbs
Dirección de domicilio
Ciudad, Estado
Código postal
Número de teléfono
Correo electrónico
Método de comunicación preferido
Estado civil
Single
In a relationship
Married
Separated
Divorced
Other
Nombre de la pareja (si aplica)
¿Cuál es el nivel más alto de educación que has completado?
High school diploma or GED
Associate degree
Bachelor’s degree
Master’s degree
Professional degree
Doctoral degree
¿Qué idioma hablas con fluidez?
English
Spanish
Chinese
Vietnamese
Tagalog
Arabic
French
Korean
Russian
German
Haitian Creole
Portuguese
Japanese
Polish
Urdu
Hindi
Persian
Bengali
Greek
Italian
Hebrew
Thai
Armenian
Punjabi
Turkish
Other
¿Cuál es tu ocupación?
Accountant
Actress
Artist
Bartender
Biologist
Cashier
Childcare worker
College professor
Cook
Customer service representative
Data entry clerk
Dental assistant
Dietitian
Elementary school teacher
Freelancer
Graphic designer
Hair stylist
Home health aide
Homamaker
HR specialist
Librarian
Medical assistant
Musician
Nurse
Nursing assistant
Paralegal
Personal care aide
Pharmacist
Physical therapist
Psychologist
Radiologic technician
Receptionist
Retail salesperson
Secretary
Self-employed
Social worker
Special education teacher
Speech-language pathologist
Student
Teaching assistant
Unemployed
Volunteer
Waitress
Other
¿Cuántas horas a la semana?
0–5 hours
6–10 hours
11–15 hours
16–20 hours
21–25 hours
26–30 hours
31–35 hours
36–40 hours
41–45 hours
46–50 hours
51+ hours
¿Cuál es tu tarifa por hora?
$15 – $20/hour
$21 – $25/hour
$26 – $30/hour
$31 – $35/hour
$36 – $40/hour
$41 – $50/hour
$51 – $60/hour
Describe brevemente tus tareas diarias en el trabajo
Si no, por favor explica
Si no, por favor explica
¿Cuándo fue tu último Papanicolaou y cuál fue el resultado?
Within the last year
1–2 years ago
2–3 years ago
More than 3 years ago
Never had one
Don’t remember
Si es así, por favor explica.
Si es así, ¿cuál(es)?
Si es así, ¿cuál(es)?
¿Cuántas veces has estado embarazada?
¿Has sido gestante subrogada anteriormente?
No, I have never been a gestational surrogate
Yes, once
Yes, twice
Yes, three times
Yes, four or more times
Si es así, por favor indica el año y cuántas semanas de embarazo tenías en cada caso.
Si es así, por favor indica el/los año(s).
Si es así, por favor explica la razón de la cesárea.
Planned C-section (non-medical/personal choice)
Repeat C-section
Failure to progress in labor
Fetal distress
Breech or abnormal fetal position
Placenta previa
Placental abruption
Multiple gestation (twins, triplets, etc.)
Large baby (macrosomia)
Maternal health conditions (e.g., preeclampsia, diabetes)
Umbilical cord issues
Infection or fever during labor
Previous uterine surgery or complications
Si es así, por favor explica.
Nombre del primer hijo
Peso al nacer
Under 5 lb 8 oz (2,500 g) – Low birth weight
5 lb 8 oz – 6 lb 15 oz (2,500–3,150 g)
7 lb – 7 lb 15 oz (3,175–3,600 g)
8 lb – 8 lb 15 oz (3,625–4,050 g)
Over 9 lb (4,100 g+)
¿Cuántas semanas de embarazo tenías al momento del parto?
37 weeks
38 weeks
39 weeks
40 weeks
41 weeks
42 weeks or more
Fecha de parto
¿Cómo describirías tu experiencia general con el embarazo?
Very positive – I enjoyed being pregnant and had minimal complications
Positive – Overall good experience with some manageable symptoms
Neutral – Mixed experience; neither particularly good nor bad
Somewhat difficult – Experienced moderate discomfort or complications
Difficult – Significant challenges or complications during pregnancy
Other
Enumera cualquier complicación que hayas tenido durante tu embarazo
None
High blood pressure (hypertension)
Preeclampsia
Gestational diabetes
Preterm labor
Placenta previa
Placental abruption
Hyperemesis gravidarum (severe nausea/vomiting)
Incompetent cervix
Intrauterine growth restriction (IUGR)
Group B strep infection
Anemia
Excessive weight gain or weight loss
Multiple pregnancy (twins, triplets, etc.)
Nombre del segundo hijo (si aplica)
Peso al nacer
Under 5 lb 8 oz (2,500 g) – Low birth weight
5 lb 8 oz – 6 lb 15 oz (2,500–3,150 g)
7 lb – 7 lb 15 oz (3,175–3,600 g)
8 lb – 8 lb 15 oz (3,625–4,050 g)
Over 9 lb (4,100 g+)
¿Cuántas semanas de embarazo tenías al momento del parto?
Fecha de parto
Nombre del tercer hijo (si aplica)
Peso al nacer
Under 5 lb 8 oz (2,500 g) – Low birth weight
5 lb 8 oz – 6 lb 15 oz (2,500–3,150 g)
7 lb – 7 lb 15 oz (3,175–3,600 g)
8 lb – 8 lb 15 oz (3,625–4,050 g)
Over 9 lb (4,100 g+)
¿Cuántas semanas de embarazo tenías al momento del parto?
Fecha de parto
¿Cómo describirías tu experiencia general con el embarazo?
Very positive – I enjoyed being pregnant and had minimal complications
Positive – Overall good experience with some manageable symptoms
Neutral – Mixed experience; neither particularly good nor bad
Somewhat difficult – Experienced moderate discomfort or complications
Difficult – Significant challenges or complications during pregnancy
Other
Enumera cualquier complicación que hayas tenido durante tu embarazo
None
High blood pressure (hypertension)
Preeclampsia
Gestational diabetes
Preterm labor
Placenta previa
Placental abruption
Hyperemesis gravidarum (severe nausea/vomiting)
Incompetent cervix
Intrauterine growth restriction (IUGR)
Group B strep infection
Anemia
Excessive weight gain or weight loss
Multiple pregnancy (twins, triplets, etc.)
Enumere aquí todos los partos adicionales con detalles. Por favor, asegúrese de incluir: Nombre, fecha de nacimiento, género, peso al nacer, semanas de embarazo al momento del parto, método de parto y cualquier complicación.
¿Cómo te describirías mejor?
Nurturing and compassionate
Emotionally stable and resilient
Responsible and reliable
Health-conscious and active
Family-oriented
Open and communicative
Positive and optimistic
Organized and detail-oriented
Independent but cooperative
Calm under pressure
Experienced with children or pregnancy
Spiritually grounded or faith-based
Motivated to help others
Respectful of others’ boundaries and values
Other
¿Cuáles son tus metas para los próximos 5 años?
Advancing in my career or starting a new one
Going back to school or completing a degree
Improving my financial stability
Buying a home or moving to a new place
Prioritizing my physical and mental health
Traveling and experiencing new cultures
Building stronger relationships with my family
Growing personally or spiritually
Starting or expanding my own family
Giving back to others in a meaningful way
Other
¿Te consideras financieramente estable?
Yes, I have steady income and am financially stable
Yes, I have a stable job and manage my finances well
I’m financially stable but plan carefully for unexpected expenses
No, I’m working towards stability but confident in the surrogacy process
No, I have financial concerns but am seeking support through the process
¿Qué pasatiempos disfrutas?
Spending time with family and loved ones
Staying active
Creative activities
Cooking or baking
Reading or writing
Helping others
Personal growth
Traveling or exploring new places
Home and lifestyle
Other
¿Qué disfrutan hacer en familia?
Cooking and sharing meals together
Spending time outdoors (e.g., walks, parks, hiking)
Playing games or doing fun activities at home
Watching movies or family shows
Attending community or school events
Traveling or taking weekend trips
Going to church or spiritual gatherings
Volunteering or giving back together
Celebrating holidays and family traditions
Just relaxing and enjoying each other's company
Other
¿Con quién vives?
I live alone
I live with my spouse or partner
I live with my children
I live with my parents or other family members
I live with roommates or friends
Other
¿Te encuentras en un hogar y condiciones de vida estables en este momento?
¿Quién te apoyará física y emocionalmente durante tu proceso de subrogación?
My spouse or partner
My children
My parents
Extended family
Close friends
A support group or community network
A therapist or counselor
I prefer to manage on my own
¿Tienes cuidado infantil disponible para citas médicas y reposo?
Yes, I have consistent childcare support from my spouse or partner
Yes, I have reliable help from family or close friends
Yes, I have a paid childcare provider or flexible daycare option
I have multiple backup options for childcare when needed
I can arrange childcare as needed, but it may require planning
I do not currently have consistent childcare available
¿Cuáles son tus razones personales para querer ser gestante subrogada?
I want to help others build a family
I enjoy being pregnant and had positive experiences
I feel called to give back in a meaningful way
I know someone who struggled with infertility
I want to make a difference in someone’s life
I have completed my own family and want to help someone else
I’m inspired by other surrogates or stories I’ve seen
I’m seeking a purpose-driven experience
I want to contribute financially to my family in a meaningful way
Other
¿Qué tipo de relación te gustaría tener con los padres intencionales durante el proceso?
Open and friendly communication
Regular check-ins and updates
Occasional contact with clear boundaries
A close and ongoing relationship
Professional and respectful interaction
In-person involvement when possible
Virtual communication only (texts, calls, video)
I’m flexible and open to what feels right for both sides
I prefer limited contact during the process
¿Qué tipo de relación te gustaría tener con los padres intencionales y el(los) bebé(s) después del nacimiento?
Occasional updates or photos from the intended parents
A continued friendship with the intended parents
Open communication with mutual check-ins
Being available if the child wants to know about their birth story in the future
Staying connected like extended family
Minimal contact after birth unless needed
No ongoing relationship, and I’m comfortable with that
I’m open and flexible based on what the intended parents prefer
En caso de que quedes embarazada de múltiples, ¿estarías de acuerdo con una reducción a un embarazo gemelar o único en cualquiera de los siguientes casos?
Request of the intended parent(s)
Only if your health was a concern
¿Existiría alguna razón por la que no estarías dispuesta a interrumpir el embarazo de subrogación?
I am personally comfortable with termination if medically advised
I would follow the wishes of the intended parents as outlined in our agreement
I would be willing only under certain medical circumstances
I am not comfortable with termination for any reason
I am undecided and would need to discuss this further with the agency
Other
¿Tu familia apoya tu decisión de ser gestante subrogada? ¿Hay alguien que no lo apoye?
Yes, my spouse or partner is fully supportive
Yes, my children (if applicable) understand and support my decision
Yes, my extended family (parents, siblings, etc.) are supportive
Most people close to me are supportive
I’ve had mixed responses but feel confident in my decision
One or more family members are not supportive
I haven’t told all my family yet
¿Cómo puedes asegurar a los padres intencionales que no abandonarás el compromiso una vez que el contrato de subrogación entre en vigor?
I am fully committed and have a strong support system
I understand the responsibilities and am ready for the commitment
I have carefully considered and am confident in my decision
I understand the contract and expectations from both sides
I have a history of following through on commitments
I have professional support to stay focused on the process
I am financially stable and free of external pressures
Other
Enviar
