Donor questionnaire – Gezonde Darmflora

Please enable JavaScript in your browser to complete this form.

Personal data

Name *

First

Last

Date of birth *

E-mail *

Mobile phone *

Address

Address Line 1

City

State / Province / Region

Postal Code

Country

Gender *

Male
Female

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? *

Medical History

Were you born naturally or by caesarean section? *

Naturally
Caesarean section

Do you have any children? *

Have you ever been rejected during an examination (as a donor or otherwise)? *

Why *

Have you ever donated blood? *

If so when was the last time? *

Have you ever been to a specialist (doctor in the hospital)? *

When? *

Are you vaccinated for covid-19? *

How many times? *

Which manufacturer? *

Do you take medicines? *

If so, what medications did you receive? *

In what year was this treatment started? *

Have you been depressed in the past? *

When did this start and for how long? *

Have you taken any medication for this? *

Chronic Disorders and Heredity

Have you been treated for autism? *

Have you ever been tested for diabetes? *

What was the result? *

Does diabetes run in the family? *

Is there a family history of schizophrenia/bipolar or anxiety disorders? *

Does Creuzfeldt Jakob disease run in your family? *

Does dementia run in your family before the age of 60? *

Environment and Risk Areas

Do you have any pets? *

Were you born in a country outside Europe or have you lived longer in a country outside Europe for 5 years? *

Where and when? *

Did you stay in the UK for more than 6 months between 1980 and 1996 combined? *

Have you been to the tropics in the last two years? *

Where and in what year? *

Have you ever had malaria? *

In what year? *

Do you know which type? *

Have you ever had special infectious diseases? *

Which infectious diseases? *

Occupational and exposure risk

Do you have an occupational risk of blood-borne infectious diseases? (currently daily patient contact) *

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?) *

Have you ever been administered blood products into the bloodstream? (e.g.Blood transfusions)? *

When? *

Risk behaviour

Have you ever injected drugs into your veins (intravenously)? *

Have you ever snorted drugs? *

Have you ever had a tattoo? *

If so, in which country was it placed and when? *

Have you ever had a piercing/earrings done? *

If so, in which country was it set? *

Have you ever had acupuncture? *

If so in which country? *

Have you ever had growth hormone treatment? *

Have you ever had a tissue donation? (eg cornea) *

Have you ever had a hair transplant? *

Have you ever had surgery or clinical treatment done abroad? *

If so, where and when? *

Have you gained a new sexual partner in the past year? *

Have you ever had sexual contact with an intravenous drug user? *

Have you ever had sexual contact with someone who was subsequently found to be infected with HIV/HTLV/Hepatitis/Lues? *

With what? *

HIV
Lues
Hepatitis
HTLV
Other:

Other: *

Have you ever had a sexually transmitted disease (STD)? *

Which one? *

Vaccinations

Have you been vaccinated (i.e. not a single immunoglobulin injection) for Hepatitis A? *

Was the titer sufficient? *

Have you been vaccinated (i.e. not a single immunoglobulin injection) for Hepatitis B? *

Was the titer sufficient? *

Do hereditary diseases run in the family? *

Which ones? *

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? *

Do you suffer from excessive daily flatulence (flatulence)? *

If so, how often is this on average in a day? *

Have you ever been treated for an intestinal infection? *

When was the last time? *

Do you have a chronic bowel disease? (e.g. Crohn's disease/Ulcerative colitis/Celiac disease) *

If so, which one? *

Do you ever drink products especially for your bowel movements? (activities/yakult/actimel etc?) *

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? *

If so, how often is this on average per month? *

... times

Do you suffer from hemorrhoids? *

Do you often have intestinal cramps? *

Do you ever take medication to facilitate/slow down bowel movements? *

Do you ever take certain foods (plums/fibres) to help with bowel movements? to ease? *

Do bowel disorders run in your family? *

If so, which ones and with whom? *

Does colon cancer or polyps run in your family? *

With whom? *

At what age? *

Antibiotic use

Have you ever taken antibiotics? *

Have you taken antibiotics in the past three months? *

Can you remember which antibiotic? *

When and for how many days? *

Have you used antibiotics in the past year? *

Can you remember which antibiotic? *

so in

When and for how many days? *

Additional Health Issues

Have you ever experienced rectal bleeding? *

Has additional research been carried out? *

What were the results? *

Have you had a fever in the past two weeks? *

Have you had diarrhoea in the last 3 months? *

When did this start and how long did it last? *

Do you suffer from allergies? *

Additions

Are there any other things you would like to say or explain?