TML-QA-FRM-078-01-Autologous FMT Step 1 of 14 7% Document ID Version Title Effective date: TML-QA-FRM-078-01 01 Autologous FMT Donor Questionnaire 26 JUN 2026 Author: GURBET MACKINNONDate: 16 JUN 2026 Approver: GUMAN SINGHDate: 18 JUN 2026 Page 1 of 15 Before You Begin Before proceeding to the health questionnaire, we kindly ask for your consent to collect and process your personal data. The questionnaire will request information about your medical history, lifestyle, and other relevant details. This information is essential for us to determine your health status and eligibility as a donor. Your Privacy Matters We are committed to protecting your personal data in accordance with the UK General Data Protection Regulation (GDPR). All information provided will be kept confidential and used solely for donor screening purposes. For more details on how we handle your data, please review our Privacy Notice. Consent to ProceedBy agreeing to proceed with the questionnaire, you are providing your consent to provide us with your information for use in our donor screening(Required) Yes, I would like to proceed No I have read the privacy policy(Required) I consent to TML.science contacting me. Please see our Privacy Policy to find out more Document ID Version Title Page 2 of 15 TML-QA-FRM-074-01 01 Autologous FMT Donor Questionnaire 1. Personal / Contact Details:Date(Required) DD slash MM slash YYYY Gender(Required)First Name:(Required)Surname:(Required)Address(Required)Email Address(Required) Telephone Number:(Required)Date of Birth (DD/MM/YYYY):(Required) DD slash MM slash YYYY Country of Birth:(Required)Height (cm):(Required)Weight (Kg):(Required)Ethnicity:(Required)Occupation:(Required)Next of Kin:(Required)2.Is your working environment high risk for transmission of disease and does your work or volunteering involve handling human or primate brain tissue or handling farm animals?(Required) Yes No If yes, please provide details: Document ID Version Title Page 3 of 15 TML-QA-FRM-074-01 01 Autologous FMT Donor Questionnaire 3. Do you currently follow any particular diet (tick all that apply)?(Required) None Vegetarian Vegan Pescatarian Ketogenic Atkins Paleo Gluten-Free Other If Other, please specify4. How often do you have a bowel movement?(Required) Daily Every 2 days Every 3 days Irregular 5. Using Bristol Stool Chart, please state your usual Consistency?(Required) Type 1 Type 2 Type 3 Type 4 Type 5 Type 6 Type 7 6. In the past 4 weeks, have you experienced diarrhoea?(Required) Yes No 7. In the last 3 months have you consistently (>25% of bowel movements) experienced any of the following? Please tick all that apply(Required) Straining Lumpy or Hard Stools Sensation of incomplete evacuation Sensation of obstruction or blockage None of above Document ID Version Title Page 4 of 15 TML-QA-FRM-074-01 01 Autologous FMT Donor Questionnaire 8. In the last 3 months have you consistently (at least 3 days/month) experienced any of the following? Please tick all that apply(Required) Recurrent bloating Recurrent abdominal pain Mucus in the stool Blood in the stool None of above 9. Any unusual stool or sickness related symptoms (e.g. fever, vomiting, nausea in the past 4 weeks?(Required) Yes No If yes, please specify10. Have you ever had blood in your stool?(Required) Yes No 11. Have you ever taken laxatives or anti-diarrhoea medication?(Required) Yes No Document ID Version Title Page 5 of 15 TML-QA-FRM-074-01 01 Autologous FMT Donor Questionnaire SECTION 2- MEDICAL HISTORY -GI, LIVER, ALLERGIES12. In the past year, have you been diagnosed by a physician with any of the following? (please tick all that apply)(Required) Not Applicable Chronic Constipation Chronic Diarrhoea Helicobacter Pylori Peptic ulcer disease (i.e. stomach ulcer) Chronic Haemorrhoids Other gastrointestinal conditions If Other, please specify13. Have you ever been diagnosed by a doctor with any of the following? (please tick all that apply)(Required) Not Applicable Inflammatory bowel disease (e.g. Crohn's disease, ulcerative colitis, etc.) Irritable bowel syndrome (e.g. IBS-diarrhoea, IBS-constipation, etc.) Chronic liver disease (e.g. non-alcoholic fatty liver disease, primary sclerosing cholangitis, etc.) Celiac Disease Other Intestinal or Liver condition If Other, please specify14. Have you been diagnosed with Allergies (please tick all that apply)(Required) Not Applicable Atopic Dermatitis Eczema Seasonal/Pollen Allergy Pet Allergy Food Allergy 15. If you have had symptoms in the last 3 months, have you been on any medication to manage symptoms?(Required) Yes No If yes, please provide details: Document ID Version Title Page 6 of 15 TML-QA-FRM-074-01 01 Autologous FMT Donor Questionnaire 16. Do you have any systematic autoimmune conditions?(Required) Yes No 17. Do you have any history of atopy? (e.g. asthma, eosinophilic disorders)(Required) Yes No SECTION 3- MEDICAL HISTORY -CVD, METABOLIC, NEUROLOGICAL, CANCER18. Have you ever been diagnosed with any of the following conditions? (please tick all that apply)(Required) Not Applicable Diabetes (Type I or II) Metabolic syndrome High Blood Pressure High Cholesterol Obesity Heart Disease (e.g. atherosclerosis, myocardial infarction, congestive heart failure) Other cardio/metabolic condition If yes, please provide details:19. If you reported a condition in the previous question, do you currently take any medication/treatments to manage your condition?(Required) Yes No Not Applicable If yes, please provide details:20. Have you ever been diagnosed with any of the following conditions? (please tick all that apply)(Required) Not Applicable Fibromyalgia Chronic Fatigue Syndrome Other chronic pain (please specify) If Other, please specify:21. If you reported a condition in the previous question, do you currently take any medication/treatments to manage your condition?(Required) Yes No Not Applicable If yes, please provide details: Document ID Version Title Page 7 of 15 TML-QA-FRM-074-01 01 Autologous FMT Donor Questionnaire 22. Have you ever been diagnosed with the following neurological disorders? (please tick all that apply)(Required) Not Applicable Autism Spectrum Disorder (e.g. Asperger's syndrome) Epilepsy Multiple Sclerosis Parkinson Disease Other neurological conditions (please specify) If Other, please specify:23. If you reported a condition in the previous question, do you currently take any medication/treatments to manage your condition?(Required) Yes No Not Applicable If yes, please provide details:24. Have you ever been diagnosed by a clinician (e.g. physician or psychologist) with any of the following? (please tick all that apply)(Required) Not Applicable Depression Anxiety (e.g. Generalised anxiety disorder) Bipolar disorder Schizophrenia Eating disorder Other (please specify) If Other, please specify: Document ID Version Title Page 8 of 15 TML-QA-FRM-074-01 01 Autologous FMT Donor Questionnaire 25. If you reported a condition in the previous question, do you currently take any medication/treatments to manage your condition in the last 3 months?(Required) Yes No Not Applicable If yes, please provide details:26. Do you have a medical history of anxiety (Generalized anxiety disorder)?(Required) Yes No Unsure 27. Do you have a medical history of depression or frequently feel depressed/or a sense of hopelessness?(Required) Yes No If yes, please provide details:28. Do you have history of polyposis (e.g. adenomatous polyps, seated polyps)?(Required) Yes No If yes, please provide details:29. Do you have/had any other form of cancer?(Required) Yes No If yes, please provide details: Document ID Version Title Page 9 of 15 TML-QA-FRM-074-01 01 Autologous FMT Donor Questionnaire SECTION 4- MEDICAL HISTORY -INFECTIONS 30. Have you ever been diagnosed with the following infections? (please tick all that apply)(Required) Not Applicable Sexually Transmitted Disease (e.g. Syphilis, Gonorrhoea, Chlamydia, Trichomoniasis) Genital Herpes HPV HIV Hepatitis (A,B,C,D or E) Tuberculosis 31. Have you ever been diagnosed with Lyme’s Disease(Required) Yes No 32. Have you ever had a tick-bite in the last 6 months?(Required) Yes No 33. Diagnosed with Creutzfeldt-Jakob disease (CJD) or known exposure to person with CJD?(Required) Yes No 34. Have you got any cold sores, anal fissures, anal ulcers, anal sores or pruritus ani within the past 3 months?(Required) Yes No If yes, please provide details:35. Do you ever get cold sores?(Required) Yes No If yes, please provide details:36. Have you had an antibiotic-resistant infection? (please tick all that apply)(Required) Not Applicable Methicillin-resistant staphylococcus aureus (MRSA) Carbapenem-resistant Enterobacteriaceae (CRE) Extended spectrum beta-lactamase (ESBLs) Vancomycin-resistant enterococcus (VRE) Other (please specify) If Other, please specify:37. Have you got any haemorrhoids, internal or external?(Required) Yes No 38. Do you currently have, or have you ever had tuberculosis?(Required) Yes No 39. Do you have any history of Malaria disease?(Required) Yes No 40. Have you tested for Monkey pox ? Or have been close to someone diagnosed with Monkeypox?(Required) Yes No 41. Have you been positive for Covid-19 in the last 8 weeks?(Required) Yes No 42. Are you being followed by any medical specialists for any conditions at the moment?(Required) Yes No If yes, please provide details:SECTION 5- MEDICAL HISTORY -CLINICAL PROCEDURES43. Have you ever had any major gastrointestinal surgery (e.g. gastric bypass, colonic resection etc)?(Required) Yes No 44. In the last 12 months, have you received blood/blood product transfusion?(Required) Yes No 45. Any other medical or surgery history?(Required) Yes No 46. Have you ever had an organ or tissue transplant?(Required) Yes No Document ID Version Title Page 11 of 15 TML-QA-FRM-074-01 01 Autologous FMT Donor Questionnaire SECTION 6- MEDICATION HISTORY47. Do you currently take any oral or topical medications (prescription or non-prescription, including seasonal medications)?(Required) Yes No If yes, please provide details (name &frequency):48. Do you take any immunosuppressive medications (e.g. steroids, glucocorticoids, calcineurin inhibitors, systemic antineoplastic agents, etc.)(Required) Yes No If yes, please provide details (name &frequency):49. In the last 6 months, have you had any oral or topical antibiotics?(Required) Yes No If yes, please provide details (name &frequency):50. In the last 8 weeks, have you had any oral or topical antifungals?(Required) Yes No If yes, please provide details (name &frequency):51. In the last 6 months, have you had any antiviral (e.g. Tamiflu) ?(Required) Yes No If yes, please provide details (name &frequency):52. Do you have any history of receiving an experimental medicine or vaccine?(Required) Yes No If yes, please provide details:53. Have you received a live attenuated virus within the last six months?(Required) Yes No Document ID Version Title Page 12 of 15 TML-QA-FRM-074-01 01 Autologous FMT Donor Questionnaire 54. Do you have any history of receiving growth hormone from human pituitary glands, insulin from cows, clotting factor concentrates or known risk of prion disease?(Required) Yes No 55. Do you use any recreational or illicit drugs?(Required) Yes No 56. Have you taken any proton inhibitors, statin, immunosuppression or chemotherapy drugs?(Required) Yes No If yes, please provide details:57. For Female Donors : Are you currently pregnant?(Required) Yes No Not Applicable 58. For Female Dpnors: Are you currently breast feeding?(Required) Yes No Not Applicable 59. Is there anything we might have missed regarding your health condition (genetic or acquired) that we should be aware of? If so, please provide details(Required) Yes No If yes, please provide details:60. Have you ever had an operation or had to be hospitalised?(Required) Yes No Not Applicable Document ID Version Title Page 13 of 15 TML-QA-FRM-074-01 01 Autologous FMT Donor Questionnaire SECTION 7- LIFESTYLE RISK FACTORS61. Have you had a blood transfusion?(Required) Yes No If yes, please provide details:62. Have you taken part in unprotected sex (outside a primary monogamous relationship), had any kind of STD or participated in homosexual intimate contact in the last 12 months?(Required) Yes No 63. Have you ever been involved in work as a sex worker or used the services of a sex worker?(Required) Yes No 64. Have you had sex with somebody that was diagnosed with HTLV-1 and 2, hepatitis or has had a positive test for infectious disease?(Required) Yes No 65. Have you ever used any intranasal or intravenous drug use outside of hospital settings or medicinal purpose?(Required) Yes No 66. Are there any other lifestyle factors you engage in that could put you at risk for infection?(Required) Yes No If yes, please specify67. Please provide details of your foreign travel history over the last 6 months.(Required) Yes No If yes, please specify68. Please indicate how you discovered the TML.science Autologous FMT donor service.(Required)Thank you for completing this questionnaire. We will be in touch with you shortly. Document ID Version Title Page 14 of 15 TML-QA-FRM-074-01 01 Autologous FMT Donor Questionnaire Justification (N/A if not applicable): Activity Status (Pass/Fail) Signature & Date Production Supervisor/Manager Medical Officer Quality Assurance Document ID Version Title Page 15 of 15 TML-QA-FRM-074-01 01 Autologous FMT Donor Questionnaire
