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How does it work?
Gut flora
Gut flora
Immune system
Disturbed intestinal flora
Good and bad bacteria
Intestinal problems
Intestinal problems
Diarrhea
Bloated feeling
Flatulence
Constipation
Irritable bowel syndrome
FMT theory
Testing yourself
Donate
About
Shop
How does it work?
Gut flora
Gut flora
Immune system
Disturbed intestinal flora
Good and bad bacteria
Intestinal problems
Intestinal problems
Diarrhea
Bloated feeling
Flatulence
Constipation
Irritable bowel syndrome
FMT theory
Testing yourself
Donate
About
Shop
Blog
Customer service
Question and answer
Contact
English
Nederlands
Donor questionnaire
Please enable JavaScript in your browser to complete this form.
Please enable JavaScript in your browser to complete this form.
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Step
1
of 12
Personal data
Date of birth
*
Mobile phone
*
Address
*
Gender
*
Male
Woman
Next
Body Data and General Health
What is your weight?
*
In kilo
What is your height?
*
In CM
Wat is your BMI?
*
In cm/kg2
What is your profession/study?
*
What is your education level?
*
What is your family composition?
*
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Next
Medical History
Were you born naturally or by caesarean section?
*
Naturally
Caesarean section
Do you have any children?
*
Yes
No
Have you ever been rejected during an examination (as a donor or otherwise)?
*
Yes
No
Why
*
Have you ever donated blood?
*
Yes
No
If so when was the last time?
*
Have you ever been to a specialist (doctor in the hospital)?
*
Yes
No
When?
*
Are you vaccinated for covid-19?
*
Yes
No
How many times?
*
Which manufacturer?
*
Do you take medicines?
*
Yes
No
If so, what medications did you receive?
*
In what year was this treatment started?
*
Have you been depressed in the past?
*
Yes
No
When did this start and for how long?
*
Have you taken any medication for this?
*
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Next
Chronic Disorders and Heredity
Have you been treated for autism?
*
Yes
No
Have you ever been tested for diabetes?
*
Yes
No
What was the result?
*
Does diabetes run in the family?
*
Yes
No
Is there a family history of schizophrenia/bipolar or anxiety disorders?
*
Yes
No
Does Creuzfeldt Jakob disease run in your family?
*
Yes
No
certain a or
Does dementia run in your family before the age of 60?
*
Yes
No
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Next
Environment and Risk Areas
Do you have any pets?
*
Yes
No
Were you born in a country outside Europe or have you lived longer in a country outside Europe for 5 years?
*
Yes
No
Where and when?
*
Did you stay in the UK for more than 6 months between 1980 and 1996 combined?
*
Yes
No
Have you been to the tropics in the last two years?
*
Yes
No
Where and in what year?
*
Have you ever had malaria?
*
Yes
No
In what year?
*
Do you know which type?
*
Have you ever had special infectious diseases?
*
Yes
No
Which infectious diseases?
*
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Next
Occupational and exposure risk
Do you have an occupational risk of blood-borne infectious diseases? (currently daily patient contact)
*
Yes
No
If yes, namely?
*
Have you ever had a needlestick injury? (for example, an injury with a needle smeared with blood from someone else, or another sharp with blood smeared object?)
*
Yes
No
Have you ever been administered blood products into the bloodstream? (e.g.Blood transfusions)?
*
Yes
No
When?
*
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Next
Risk behaviour
Have you ever injected drugs into your veins (intravenously)?
*
Yes
No
Have you ever snorted drugs?
*
Yes
No
Have you ever had a tattoo?
*
Yes
No
If so, in which country was it placed and when?
*
Have you ever had a piercing/earrings done?
*
Yes
No
If so, in which country was it set?
*
Have you ever had acupuncture?
*
Yes
No
If so in which country?
*
Have you ever had growth hormone treatment?
*
Yes
No
Have you ever had a tissue donation? (eg cornea)
*
Yes
No
Have you ever had a hair transplant?
*
Yes
No
Have you ever had surgery or clinical treatment done abroad?
*
Yes
No
If so, where and when?
*
Have you gained a new sexual partner in the past year?
*
Yes
No
Have you ever had sexual contact with an intravenous drug user?
*
Yes
No
Have you ever had sexual contact with someone who was subsequently found to be infected with HIV/HTLV/Hepatitis/Lues?
*
Yes
No
With what?
*
HIV
Lues
Hepatitis
HTLV
Other:
Other:
*
Have you ever had a sexually transmitted disease (STD)?
*
Yes
No
Which one?
*
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Next
Vaccinations
Have you been vaccinated (i.e. not a single immunoglobulin injection) for Hepatitis A?
*
Yes
No
Was the titer sufficient?
*
Yes
No
Have you been vaccinated (i.e. not a single immunoglobulin injection) for Hepatitis B?
*
Yes
No
Was the titer sufficient?
*
Yes
No
Do hereditary diseases run in the family?
*
Yes
No
Which ones?
*
Previous
Next
What type of stool do you have?
*
Type 1
Type 2
Type 3
Type 4
Type 5
Type 6
Type 7
Gut Health
How many times a day do you have bowel movements on average?
*
Do you have a regular stool pattern?
*
Yes
No
Do you suffer from excessive daily flatulence (flatulence)?
*
Yes
No
If so, how often is this on average in a day?
*
Have you ever been treated for an intestinal infection?
*
Yes
No
When was the last time?
*
Do you have a chronic bowel disease? (e.g. Crohn's disease/Ulcerative colitis/Celiac disease)
*
Yes
No
If so, which one?
*
Do you ever drink products especially for your bowel movements? (activities/yakult/actimel etc?)
*
Yes
No
How many times?
*
... times per day
Do you ever (more than once a month) suffer from difficult bowel movements (constipation) so that you have to strain for a long time to get the stool out?
*
Yes
No
If so, how often is this on average per month?
*
... times
Do you suffer from hemorrhoids?
*
Yes
No
Do you often have intestinal cramps?
*
Yes
No
Do you ever take medication to facilitate/slow down bowel movements?
*
Yes
No
Do you ever take certain foods (plums/fibres) to help with bowel movements? to ease?
*
Yes
No
Do bowel disorders run in your family?
*
Yes
No
If so, which ones and with whom?
*
Does colon cancer or polyps run in your family?
*
Yes
No
With whom?
*
At what age?
*
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Next
Antibiotic use
Have you ever taken antibiotics?
*
Yes
No
Have you taken antibiotics in the past three months?
*
Yes
No
Can you remember which antibiotic?
*
When and for how many days?
*
Have you used antibiotics in the past year?
*
Yes
No
Can you remember which antibiotic?
*
When and for how many days?
*
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Next
Additional Health Issues
Have you ever experienced rectal bleeding?
*
Yes
No
Has additional research been carried out?
*
Yes
No
What were the results?
*
Have you had a fever in the past two weeks?
*
Yes
No
Have you had diarrhoea in the last 3 months?
*
Yes
No
When did this start and how long did it last?
*
Do you suffer from allergies?
*
Yes
No
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Next
Additions
Are there any other things you would like to say or explain?
Send