Donor Screening Questionnaire

 

You are being asked to consider donation of feces (stool) for fecal microbiota transplantation (FMT) to treat patients with various health conditions and further medical research on intestinal microorganisms.

To be a donor, it is necessary that you meet certain criteria.  These criteria are present to ensure you can provide a healthy and safe donation for FMT.  During your “screening” visits, you will be asked a number of questions by the doctor (and possibly a study coordinator, if the FMT is being done as part of a study) to see if you are able to donate.

We realize that some of the screening questions we need to ask are sensitive in nature or could be embarrassing to you.  Therefore, we are giving you this self-screening questionnaire that you may complete in privacy and give to us.  Please read it carefully and simply check either YES or NO at the top of the page.  In the second section (labeled question 6), there is no need for you to indicate to which option you are answering yes – just check at the top of the page if you answer YES to ANY of the options. 

If you have any questions about this questionnaire, please contact Jenita Chrysostoum (MTOP Coordinator) at 416-340-4800 Ext. 8353

Thank you.

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SELF-SCREENING QUESTIONNAIRE FOR

POTENTIAL FMT DONORS

QUESTIONS

  1. Would you be between the ages of 18-45 during the donation period?
  2. Is your Body Mass Index (BMI) be between 18.5-23? https://www.dietitians.ca/your-health/assess-yourself/assess-your-bmi/bmi-adult.aspx
  3. Are you able to do frequent visits to the study site at Toronto General Hospital and Mount Sinai Hospital for stool donation?
  4. Are you currently taking any medications including vitamins, supplements, antibiotic, prebiotic or probiotic, birth control etc.?
  5. Have you ever been told any of the following: Chagas disease; degenerative neurological disorder; autoimmune disease; and/or chronic liver disease?

Check YES if you have ANY one of the following conditions; otherwise, check NO

 

  1. Have you done any of the following in the past 12 months?
  • Received anal intercourse;
  • Used or injected drugs into the vein, muscle or skin;
  • Had sexual intercourse for money or drugs;
  • Had sex with any person described as above in a. to c.
  • Had sex with any person suspected or known to have HIV (AIDS) or Hepatitis B virus or Hepatitis C virus infection;
  • Been an inmate of a correctional facility;
  • Been in close contact with another person with active Hepatitis B virus infection (e.g., living in the same house, sharing kitchen and bathroom facilities regularly).