Microbiota Donor Questionnaire

Contact information

Your email: Re-enter Email:
Your mobile phone number:

Microbiota Donor Questionnaire(Step 1 of 3)

Let's start

Date of birth (only month and year)

Sex

Height (cm / ft'in''): Weight (kg / lbs): Body Type You were born by
Country
State/Region
Postal Code
City
Profession / Studies
Blood type (leave blank if unknown)
Are you a blood donor?
You have taken antibiotics ...
In general, how often do you take antibiotics?
Have you ever taken many antibiotics (or antifungals/antimicrobials in general) for a long period of time?
From the next image, called the Bristol Stool Chart, which number would identify the most your type of stool? Please specify your type
Is your stool type consistant everyday or it changes?

Microbiota Donor Questionnaire (2 of 3)

In general, how often do you have a bowel movement?
How often do you experience bloating or gas that will bother you?
How often do you experience diarrhea?
And constipation?
Have you ever had irritable or inflammatory bowel?
Do you prefer sweet or salty or what type of foods? (Specify)
What foods do you crave for? (leave blank if none)
What is your body fat percentage? (Leave blank if unknown)
Do you practice any sport?
How often?
Are you within a professional, semi-professional or university team?
What would you consider your athletic performance?
Do you take any sports supplements to improve performance?
Have you ever been in jail?
Do you have any chronic illness?
And any autoimmune disease? (Such as celiac disease, lupus, fibromyalgia, chronic fatigue, psoriasis, etc.)
Do you have any allergies to anything? (drugs, food or others)
Do you have any food intolerances?
Are you taking any medication at this moment or have you taken it during the last year?
Do you have any contagious or sexually transmitted disease or you had it in the past?
Have you gotten any tattoos during the last 6 months?
Do you have diabetes now or have had it in the past?
Have you had candida, herpes, any fungal or similar infection?
Have you ever had a gut infection requiring medication?
Have you ever had hemorrhoids?
Do you experience dermatitis, eczema on the skin or have you ever experienced it?
As for acne, how severe was yours?
Have you ever been diagnosed with cancer?
Have you ever been diagnosed with any type of hepatitis?
Have ever received a transplant?

Microbiota Donor Questionnaire (3 of 3)

Have you ever received a blood transfusion?
Do you have any type of baldness or alopecia?
Have you ever been diagnosed with a mental illness?
Is there anyone in your close family who suffers a mental illness (parents / grandparents / siblings)?
How often do you experience hypoglycemia (low sugar, need to eat sugar) after or during exercice?
Is your mother or maternal grandmother obese or overweight?
Is there any member of your family who has diabetes (parents / grandparents / siblings)?
Have you ever had a parasite? (worms, etc.)
Have you ever been rejected for a blood donation?
How often do you get the flu?
Have you ever been bitten by a tick or diagnosed with Lyme disease?
Do you smoke?
Has any member of your family had a congenital problem?
How many hours do you usually sleep every night?
How many times do you usually wake up at night?
Do you usually wake up before the alarm clock rings?
How long does it take you to fall asleep? (In general)
Do you fall asleep easily anywhere?
In general, how would you rate the quality of your sleep?
What have been your last joint or muscle issues? (Leave blank if none)
Do you have any root canal, any metal/amalgam or similar fillings? (Please Specify)
How is your oral health in general? (fillings, fallen pieces, infections, root canals, etc ... good bad regular ...)
Have you ever had anxiety and how does it affect you?
Have you ever had depression?
How often do you suffer from headaches or migraines?
Have you ever had any suicide attempts or someone in your close family?
Have you ever had tinnitus or ear ringing? (does not count after a loud noise/concert)
Have you or any close relative ever been diagnosed with autism, hyperactivity, schizophrenia or any similar condition?
Whats your ethnicy?
Have your tonsils been removed?
Have you had your appendix removed?
Do you have halitosis (bad breath)?
Have you ever had a surgery?
Is there any food or activities that affect the shape of your stool, diarrhea, constipation or thin stools?
How many colds do you typically get in a year?
Are you more sensitive to cold or heat?
Have you had mononucleosis (a.k.a. Epstein barr virus)?
Do you have a visible sixpack of abs?
What’s your skin type?
What’s your academic performance?
Have you been exposed to mold or is there mold in your home?(black or yellow marks in ceilings or walls)
What’s your siblings health? Has any of your siblings died or has any disease? Are they healthy? (leave blank if no siblings)
Do you need glasses?
Please describe what is the health condition of your parents and grandparents.(Obesity, diabetes, cancer, heart failure, depression, chronic fatigue, gut problems, anxiety, suicide, mental diseases, rare diseases ...). Has anyone died before 80? Why? (accident does not count)