The Center for Reproductive Health (Gestational Carriers)
1. First Name
 
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2. Last Name
 
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3. Street Address (include apartment number where appropriate)
 
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4. City
 
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5. State
 
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6. Zip Code
 
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7. What is the primary phone number you would like us to use to contact you?
 
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8. What is your date of birth?
 
   
9. What is your height?
 
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10. What is your weight?
 
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11. What is your highest level of completed education?
 
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12. How many days per week do you use tobacco in any form?
 
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13. How many days per week does your partner/spouse or roommate smoke per week?
 
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If your partner/spouse or roommate uses tobacco, what form of tobacco is used and are there any courtesy accommodations provided to you?
14. How many days per week do you drink alcoholic beverages?
 
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Please Explain
15. Have you been medically diagnosed or self-diagnosed as an alcoholic or addicted to tobacco?
 
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Please explain "Yes".
16. When is the last time you had marijuana?
 
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17. When is the last time you have used recreational or illicit drugs (cocaine, LSD, heroin, barbiturates, narcotics, opiates, amphetamines, hallucinogens, tranquilizers, PCP, steroids for non-medical reasons, or etc.)?
 
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Please explain which drugs, how often, and any additional information.
18. Have you ever had any drug or alcohol abuse?
 
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19. Have you ever filed for bankruptcy?
 
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20. What type of contraception are your currently using?
 
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Please explain "other"
21. Have you ever placed a child up for adoption?
 
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22. If you are currently breastfeeding, when do you plan to discontinue?
 
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23. What is your email address for communication with you regarding your pre-screen application?
   
23. Please verify your email address
   
24. What is your preferred password for future login reference?
   (6-20 characters with 4 or more letters and 1 or more numbers)  
25. Verify your password