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” visit, you will be asked a number of questions by the doctor (and  possibly MTOP coordinator) 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, the self-screening questionnaire is available to you on this website to complete in privacy.  Please read it carefully and simply answer either YES or NO to all the questions below.

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

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SELF-SCREENING QUESTIONNAIRE FOR

POTENTIAL FMT DONORS

  1. Were you born in or have you lived in or traveled for greater than 6 months to Central America, South America, or southeastern Mexico?
  2. Have you ever been told that you had Chagas disease?
  3. Have you had diarrhea or bloody stools in the past 3 months?
  4. Have you had a blood transfusion outside of Canada or the United States in the past 6 months?

Answer YES if you have ANY one of the following conditions; otherwise, answer NO.

  1. Have you done any of the following in the past 6 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 exposed to suspected HIV / Hepatitis B virus / Hepatitis C virus-infected blood through a needle-stick injury or contact through broken skin or mucous membrane;
    • 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);
    • Been an inmate of a correctional facility;
    • Undergone tattooing, ear piercing or body piercing in which shared instruments were used.

… if you have answered NO to all of the questions above, you may be eligible to donate. Please contact our FMT study coordinator to schedule a screening visit.