angela 's profile - Jackie Gorton Nurse Attorney

Frst name on y AnoeloCity of Residence _Wl!989I-JACQUELYNU GORTON, MSN, JDNI] I{SE AT IORNLYSurrooato Health Hi3iorv and BackqroundAre you currently employed? Ocaupahon N o XOo yo! own a cred( card? -X-no(we tollow Oave Ramsey s FPU Oebl Free plan)How ong have you been employed at yo!r current place ol business, ---IUA-How many houas pea dayp€r weeKWhat days oflhe week do you work? (ie i.r-F Sat Sun)How much rs your gross houry rate?Ma.ital SiatusMarital Status -X_Mafied -Srngle -oivorced -Lega ly Sepafated -Wdowedlf not mafiEd, are yo! crJfiently involved in a commfted relationship? Yes - NoHave yoll and/or yoLrr panner ever had any problems wLth the Law? Yes - No -X-.Desca be crrcumstances ot charges E dale(s) ofoccurlence -Have you and/or your partner ever had any flnancial problems and/or llled tor bankruplcy?Yes_ No -X- Please explaLn€tlre ol & date(s)of occlrrencePa(ners occ!patron Juvenrle correcionol Colnselor what rs your partners gross ho!ryt :l?g-i]L3.Llnsura nce lnto.tnttionAre you cl.rrently covered by a Hea th Insurance Plan? famePhy!ic.l Charact€rbticaiDate ot Brrth 08/15/84 Age -26- Race --rE]]9aug!E!e!-Herght :!l_ Weght 140lbsHa r (Check one)_x_curry_wavys$agntEye Colof ----EgY!-ComplexDn (Check one)-fet_X_medrumoafl(Barr Color -DIq4LBody type/bone structore -small -X-medium -large Blood Type

Perronal Charact€ristlcsiEthnrc Ongrn Ancestry _&lE2e?$!--Relrgion Born InloCHRISTIANHow long have you lved al your currenl address,4 YEARSHow long drd you lve at yo!r last address?2 vEARSEducationr (check one)_X_ Cornpleted High School/ SchooLAttended WNDSOR HIGH SC|IOOL --_X_ Some College / SchoolAttended SANTA ROSA JUNIOR COLLEGE-RN PROGRAM_Competed Junor College / SchoolAttended- Completed 4 Year College / SchoolAttended:__F€rtlllty Hlsiory:Advanced Degree In -Othef (Please Specrfy)/ SchooiAttendedHave you been pregnanl before yes _X_ noHow many chrldren born?Dates ot Therapeutrc Abonrons _Nl!LFor each ch ld, please wnie dale of brrth, typeof delivery (vagrnal. c-secton) set and any specal healihproblems__gr3ie ot dirt-t--T-rfpe ot-oeilre| 12111106 .___.. l.Y 9l! r07/16i09___ r._VAgLNA!L-:Healih Probl€m.N/ABirrh Weight4lb 13ozOrd you have problems wrth the pregnancy (ex Prematu€. toxemLa gestalional diabetes)? Y€s-No-xlfyes please describe ploblern treatment, and oltcorne -N/Als your padner the father ot yo!r cn(dren? Yes _X_ No -Are you Rh.? Yes - No -X- lf yes prov de the dates of Rhogarn njectlons?Oates ot Spontaneols Abortions _l!14-Have you ever been told lhat you were |nte le,Yes-No-X_lf yes when?On what basis?ls there any hrstory offertrlily problems in yourfamily (d fficully conceivrng or m sc€rrlage)? Yes -X- No -lf yes. please explarnr Mv older 5i5t9r hos been dx'd wrth edrlv nenopor.rse0d your parents have diffEulty concerving? L

Oo any ot your siblings have lertrlity problems? Mv older srst€r ho5 been dx'd with elalv menooouseOo any ol your blood relatives have ferlilrty problems? ,Ngllhgll!4q!-qlOrd your mober take drethylstrlbestrol (DES) of any other presc ptpn drug when she was pregnant wrlh you?Yes No _X_ lf yes. please explainHave you ever been a Sufiogate Mother betore? Yes X NoWere you a _Gestat onal Carlier -OR-Tradrlional (artificral insemrnation) Carner0escfrbe PregnancyWas rl successfultAre your menstrua periods regular Yes -X-NoHow ong is your cycle? {counl 1" day ol your peaod as day 1)j?.g!4yg-1st day of last rnenskuat petiod _gJE!)J-Tlpe ot oln" conrrolusedOCPPeEonalHsalth HbtoryiDo you crjrenlly have allergres? Yes _X_ No -ll yes are they due to _iood -X_drugs -environmenl -otierPlease lst specrfic substances and reacton(s) produced belowToothaches or dental nfeclDns? YesDescnbe wth dalesNOYour d€t rs -vegetaran -X-non-vegetarian -poor qood -x-excellentHow (trch exercrse do you get, _ none - occasional -x- rcgllarWhat type ol exercise? AEROSIC WAL KIN6 5XWEEK (obolt o 20 nrnule rnil€lDo you smoke crgarettes? Yes - No -X- lf yes appoximate number of cgaretles per dayOoes your pannef srnoke? Yes - No -X- ll yes approximate number of cigarettes per dayOo yo! dr nk alcoholic beverages? Yes -No -X-Number ot drinks - | - lypeWeek / Month

ooyouothaveyouevelu9edi||ega|ornon.plescribeddru9s?@Please [st drug names. even r{ they may now be considered rllegal1)2)Oates taken _Dates laken0osage0osage0o yo! dnnk caffeinated beveragesuch as coffee. tea. colas? -NOlf so. approrimate number oi clJps per dayAre yoo cunently taking any medicaton prescflbed by your doctort Yes -X- No -lf so please Indcate medicatron dosage and condrtron prescabed for belowORftO cYCLENr_l Po QDFgr/Conditionqglllcc?Plig.n - -Have yo! ever had surgery? Yes _X_ No -lfyes pease explain f hod mv qollb lodder rehov€d 1112 009 d few nonlhs dfler I de,rve.ed nv sonHave yo! ever been hospitalized? Yes -No _Xlfyes pease explarnHave you ever had ablood transtuson, Yes _No _X_li yes please expla nHave you ever had malor radBtion or x-ray exposure? Yes -No -Xlfyes pleasexparnlHave you completed the 3 Hepatitis I injections? Yes -X- No - Injeclion oates -llZ?lll1-Have you ever been treated lor syphilrs? Yes - No _X_How many times?Have you ever been trealed tor gonorrhea? Yes - No _xlfyes when?How many limes,Have yo! or any of your sexual partners ever hadNSU (non-specific urethrits) _--jes _X_no -selfChlarnydia ___jes _X_no _selt -panner when?Venerealwans ___jes _X_no _sdf-pannerHerpes _Jes _X_no _selt _-Joartner when?0ale(s)0are(s)--Jranner

Other STD s? _ yeg _X_no _ sell _pannerHave you ever had any maJor illnessesuch as amoebEdyEentery, hepatlis pneumonra, mononucleosrsetc, Yes _ No _x_lf yes please explarnAn y cu nen t chron rc med ic€ | problems. cond rt ons? lf yes. pleas explainNONP3ychiatric Heatth:No -X-Have you ever been rn lhe c€le of a Counselor or Mental Health Professronal? Yes -lf yes when?For what reason?List All name(s) of Counselo(s)or Mental flealth Professional(s)NamelPhone Number {Name.Phone Number ( )NamePhone Number Il'lave hadany psychLalrjc hospitali2ationg? Yes _ No _X_ When? _D agnosisAre you c!rrently takrng any presc(ption drugs for psychiatrE reasons?-NO-1 Name and Dos€geHow Oflen?2 Name and DosageHow Oflen?Personal Hoalth: Wort HiBtory/ErpoaureiWhat Ls yolr cuire.t or most recent occupalion? I o|r1 o Stov ot home nomPtease trst alljobs you have had rn the pasl five years. and your possjblexposure to chemEals drugs andgasses. Please consrder carefullyJob 0utie8Datas of Employm.ntYear Ended06/?o09Erposgd to which drugs,chgftlcalg, or 9aaae3I

In the pasl srr monlhs have you been exposed to any ot lhe followng n youf livlng envrronmenl orwhreinvoved in hobbres, lfyes, please check the appropnale lem below and give dates and how often e.posedPlease consrder each caret!llv. EtrglgJlgToxrc ChemDalsSpriys,.... __Fumesi/Exhaustnlanlawh€nSaieF)..._ qglilig.n _!9!_9!9n ...Flea Powders/S016Asbestos/Asbestos ProdrictsCleaning Solutions/Solventsnlanlanla2xMonthAt horn€ whrie cledn|ng Imcoreful oboul ventrlotron.F.mily Health Hbtory:How many bood srbirrgs in your rmmedlate tarnily, includrng yo!aself, -3-How many males, _0_How rnany temales? _3_Have twrns or multrple b nhs occu(ed in your tarnily? Yes _X_ No _lf yes what relation to you? lsr cousihsPlease descnbe your fam ly mernbers by the tollowing phygc€i character st csEye Color Hai. Color Coftplexion Hoight BodyTypeVi3ionMother Med StigmalrsmFath€r brown lJETK lvled StigmatismMaternalGrandmothgrMat6rnalGrandtathrrPatemalG€ndmotharPatemalGrandfatherbrown F ai( 51 Med GoodlvledFat Small GoodMed 54" tuted Good

Please st below at what age membe.s ot your family died and what was lhe cause ot therr death' P easebe as sDecfic as oossrbleAge, It Llvlng Ag9 !t Tlm. of Death Caus ot D€.thMatErnel GlandmotherMatgrn.lGrandf.thet 88 Naiuralc€usesPatomal Grandmothor 70Pat€.nalGrandlatherMother 54FatherErothorBrotherBrotherSbtet 33SktetSl€tet0o you have any brolhers or siste's w.ro ded In rrfancy o' chrOhooo, --!9-lf yes whal was the calse?Are there any known genelrc drseasesthat run In your tanry? Yes _No -X_lf yes what are they?Has anyone in your larnily, Includlng youlself, expenenced recuning and/or chrontc physrcal syrnptoms thathave nol been evalualed by a physician? (Please include those symplorns that you rnay not consderseaols ) Yes _ No _X_Please explarn -

Pease look through the tollowing llst of rnedc€l problems and rndicale whrch ones yo! or one of yourrelatives have had Where appropnaie, please rndicate their reationshrp lo you For example f yoorpaternal grandfather had a giroke put PGF' in tie box under'Grandparents' for that condition Pleaseconsrder each condrtron carcfully foreach nember of your tamrlyHead AnackHea.t Drsease -from ErrthSckle-cellanem aHemophila orother bleed ngpro0lem ---------Le!xem aOther blooddisorderTuberculos sLung CancerOther LungDrsease

Ulcer of the5(Omacn ot0uoden!mGall StonesHepatrtrs A(rnfectous)Hepatrtrs B (serum)Other Liver DiseaseColon CancerCrohn's DiseaseCystrc Fibrosislntest nal CancerAny other cancet orproblem of thedlgestive syslemM€tabolic/Endoc n6Thyrord CancerAdrenalDystunctronor otsot0erHyperaclivrtyudnaayl Yo! Mothot Falher Sibling Gr.nd.panrntsKdney D sease I\4GM 1RemovedOther Disease olthe urinary Tract9AunUUncleCoualD

RectalD6orderG6nltaUReproductiveSystemiUtenne FrbrordsOvaflan CyslsCancer ot theOvanesN€urolo9icrl.lvligra nes[,4entalRetardatLonMultiple SclerossCerebrai PalsyOrsordeE ot theSpnalChodHuntrnglon sChoresGauchersO seaseWr son s DiseaseTay SachsOther Drseases ofthe NeNousSystem

SchLzophrenEManrc DepressonChnoaL0epressionGrendparcnt3Othe. MentalHealth DlsordeGrequrnn9 HosprtaltzalonMoth€rAunUUncleOther ChronrcM!scle DiseaseHeredity low backSighUSound/Sm€ll0eafness beforethe age ot 60Cata€cls beforethe age ot 50ElindnessColor BirndneEsoeviated Sept!mAny other srghl.sound smellotsoroer

Skin CancerPigmentaton0rsordelsOther Drsordersof the skinDrug Abuse.Mrsuse orAddictronEatrn9 D sorderSreast Cenc€rAny otner c€ncernol ftenlionedaboveAny otherconq[|on nolmentronedwhy do you wanto be a surogate Mother?I hdv€ wonied to helo o couDle aotnplelg lhera fomtlv tor overv lono lrna (ovea 10 vears). I con"l think of d b€ller wov to helD someone.Please describe your prevrous pfegnances@being oreglonl. I !l/ss healthv ond 50 were both of rnv chrlda€n.lf you are marned or In a committed reatronshrp have you d6cussed Slrrogacy wrllr your husband orpartne, ll so, what was hig/hereaction?yeJ! Mv husbond ond I hdve b€en discussino th€ possrbiliiv of sqfooocv |n olr fomilv fo. d nuhber ofyedas. We've be€n keepho on oDen dElooue dbolt when o oood tine woqld b€. We ore both fee|nothot our fomrlv is In o oood Dloce now lhof our fdhilv i5 conplele.Have you discussed Sufiogacy wrth any ot your famrly and triends, lf so. what was their €actron?Jve spoken wifh mv porants dnd sisteas. Mv notn thinks lhe Daoc€Js i5 too ooinful (for dnyohe) loendure. Mv fother rs onbrvol€nt Mv 5i5ler5 ore suDDor'live. Mv besl friend i5 gupporliv€ ond rs oo no

Heve you drscussed Surrogacy wrth your children? lf so, what w€s their reaction? lf not, how do yor.i plan lohandle it wth then?Not yel. Ive storted tolkiho wrih lhen obolt helDin otheas i|lo ver./ sDecrol wov. W€'vedlso beentolkrna oboul hosr hoppv thev hdke os. The nexl ihino Iwrll tolkwrlh lhe|n obout is how solne peopecon't hove bobr€s. ond how we con helD soheon else be os hooov os we ore with oar fo|nrlv.Who would provde yo! wilh support (emotional childc€re Injectrons) dunng the medical procedure andpregnancytEmot'oml SuDDorr - Mv husbond fomilv ond best f.'eid Mv rnorher rn-low ond s'srer rn_loe/ help he e,ith tnv childre . Mv husbond ond/o. best friend Cflslim will h€lg walh the inreclions.The abrlty to get to medical apporntment in the Bay Area and in your community rs crucral0o you drive? X Yes_ No_ 0oyouhaveacaQ Yes_X_ l\4ake and Yearl:b9jt-.1!!q[!9_r1]93Whet rs /oJr p. maT mears of transpoda!,on?I drrve mvself wheaever I need to oo.lf you prirnary transpona on is !navaiabJe, what wrll yorr use as an alternate?..lULhg:E&l$9!How would yo! leel about meehng the child born as a result of this sufiogacy in fltlre years?I woqld be wrllino/hoepv to heet th. child bo.n from the Jq..oaocv- ollhouoh. I would be eauollv osls rt acceptable for the pDspect&e parenls to attend doclors oflic€ vrsils and panrcrpale throughoul thepregnancy prccess? _x- yes -no -undecdedls rt acceptable for the prospective parents lo be n the delivery .oom for the brdh?_X_ yes _no _undecrdedlf the trealing physiqan prescnbes ii, wrll you undergo an amniocentesis to dagnose genetrc delecls(rnclld|ng Down s Syndrorne)? Yes _X_ No _lf pre-natal tests Indicate that the fetls had a senous brnh defect and ihe couple wanted to aborl. wou d yoube willing to go thfough w[h the abortion? f]ow wolld you teel about rt?y€s f would be sdd. bul I understond oboul the fP .rohts.Would you undergo a selectrve redlclon (salt intected Into embryo(s) through the belly al 12'" week) yorrbecofte pregnant with more than twins? Yes_X_ No_How would you feel about ,t?fto mrninize lhe ne€d for salecfrve reductronlW(l you be wil |ng to sign a parentage order so that the intended parenls' names wrll go on the br.th cenific€terather than your narne and the name ofyour partner, Yes_X_No_What do you ptan to lse your fe€ fot.^ll.^. l',^AIn your own words please descflbe your personalrty and ciaraclerlf om o lovino corino oerson. I lik€ fo helD D€oDl€. f om resooasible. but f like to hove tun.What are your hobb€s interests, and lalents? I |ke to do croffs. I |ka le4anrnond workrng on newprorecls Rrohi now I om nokrno o bhnkel tor rnv dodtl

lf yol] could pass a message on to th€ couple you would be a Surrogate tor, what would that message be?I'ln 5o excrted to helD bt|no voq the love cnd lov lhol cotnes tvilh o child. I o|n e-xc|led foa vorJ o^dls there anythrng €lse yoo would lrke to say?f dh veav .xcrled fo ehbork on fhig ioumev.lhank you tor teking the tims to cornpl.tc thls appllc.tionlI undersland lha( any signLicant misrepresentiation or omission is grounds {or dismissal frorn the surrogacyprogram and ihat I c€n lhen be held llnancially responsible for any lab. medic€l or psychologrcal coslsinvolved in fudherance oi the proposed sunogate carrier ar€ngement I declafe that all of the followrngrnformalion and statements made regardrng myself and my tarnily s health history are true and cofiecl TheFollowrng Sufiogate Candidate Health Hislory and Eackglo!nd form has been completed !nder penalty oloeflu'v uioer the aws of lhe State Of Car Ornrat4. ., ., l\ , L ., \,1-' | \ (Is'gn"tu,"Noa'e'/\lI\\t:l