page 45 CFS > NON ALLOPATHIC TREATMENTS > FECAL TRANSPLANT > DONOR SCREENING QUESTIONAIRE

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Donor Screening Questionnaire for Fecal Microbiota Transplantation Microbiome Health Research Institute

 

Questions for initial screening of donors:

 

 

 

1.      Do you have any chronic illnesses?

 

2.      Do you have any autoimmune conditions (e.g.. Grave's disease, IBD, lupus, rheumatoid arthritis, other)?

 

3.      Do you have irritable bowel syndrome or suffer from diarrhea or constipation often?

 

4.      Do you take medication on a daily basis?

 

a.       If yes, which medications and for what reason?

 

5.      Have you taken antibiotics in the last 6 months?

 

a.       If yes, why?

 

6.      Do you smoke?

 

7.      Have you ever used drugs intravenously?

 

8.      Have you ever had a tattoo?

 

9.      Have you ever been rejected as a blood donor?

 

a.       If yes, why?

 

10.  Have you ever received blood products or a blood transfusion?

 

a.       If yes, where and when?

 

11.  Have you ever received any type of transplant (e.g. organ, tissue, cornea, hair, etc.)?

 

a.       If yes, where, when, and what type?

 

12.  Were you born in a country outside the United States, or have you ever resided in a country outside the U.S. for more than 1 year?

 

a.       If yes, when and where?

 

13.  Have you traveled outside of the U.S. in the last two years?

 

a.       If yes, where and when?

 

14.  Have you ever had malaria?

 

a.       If yes, when?

 

15.  Have you received vaccinations for hepatitis B?

 

16.  While visiting another country (for work or vacation), have you ever had sexual contact with people originating from that country?

 

a.       If yes, when and where?

 

17.  Do you have a new sexual partner with whom you have commenced sexual relations within the last 12 months?

 

18.  Have you ever had anonymous sexual contacts?

 

19.  Have you ever had sexual contact with someone who uses IV drugs?

 

20.  Have you ever had sexual contact with someone of your own sex?

 

21.  Have you ever had sexual contact with a bisexual or homosexual man?

 

22.  In the last 12 months, have you had receptive anal sex with a new partner?

 

23.  Have you ever had sexual contact with someone who received money from you for this contact?

 

24.  Have you ever worked as a prostitute?

 

25.  Have you ever had sexual contact with someone who turned out to be infected with HIV, HTLV, hepatitis, or syphilis?

 

a.       If yes, which ones?

 

26.  Have you ever had a sexually transmittable disease (e.g. HIV, syphilis, hepatitis B, hepatitis C, gonorrhea, chlamydia, genital herpes, trichomonas, bacterial vaginosis, HPV, other)?

 

 

27.  Have you ever been treated for an intestinal infection (e.g. C. difficile, Salmonella, Shigella, Campylobacter, Yersinia, E. coli, rotavirus, norovirus, intestinal parasites, other)?

 

a.       If yes, which ones and when?

 

28.  Do you have hemorrhoids?

 

29.  Have you ever had blood in your stools?

 

a.       If yes, were any extra tests performed? What were the results?

 

30.  Have you had a fever in the past two weeks?

 

31.  What is your profession?

 

 

 

Note: questionnaire adapted and modified from Michael Docktor, personal communication and van Nood E, Vrieze A, Nieuwdorp M, et al. Duodenal infusion of donor feces for recurrent Clostridium difficile. N Engl J Med 2013;368:407-15.

 

 

page 45 CFS > NON ALLOPATHIC TREATMENTS > FECAL TRANSPLANT > DONOR SCREENING QUESTIONAIRE

page 44