TML-QA-FRM-078-12 Step 1 of 8 12% Document ID Version Title Effective date: TML-QA-FRM-078-12 01 Pre-Release-Autologous FMT Questionnaire 26 JUN 2026 Author: GURBET MACKINNONDate: 16 JUN 2026 Approver: GUMAN SINGHDate: 18 JUN 2026 Page 1 of 8 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 more1. Personal Details:Date(Required) DD slash MM slash YYYY First Name:(Required)Surname:(Required)Donor ID(Required)Height (cm):(Required)Weight (Kg):(Required)TML.science use only - Calculated BMI:2. I confirm that I am the original donor of this autologous FMT product.(Required) Yes No 3. Since the date of stool donation, have you been diagnosed with any new medical condition?(Required) Yes No If yes, please provide details:4. Since the date of stool donation, have you admitted to hospital for any reason?(Required) Yes No If yes, please provide details: Document ID Version Title Page 2 of 8 TML-QA-FRM-078-12 01 Pre-Release-Autologous FMT Questionnaire 5. Since the date of stool donation, have you undergone surgery or invasive medical procedures?(Required) Yes No If yes, please provide details:6. Since the date of stool donation, have you been required emergency medical treatment?(Required) Yes No If yes, please provide details:7. Since the date of stool donation, have you been experienced any significant change in your overall health?(Required) Yes No If yes, please provide details:8. Since stool storage 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 9. Since stool storage 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 10. Any unusual stool or sickness related symptoms (e.g. fever, vomiting, nausea) since stool storage ?(Required) Yes No If yes, please provide details: Document ID Version Title Page 3 of 8 TML-QA-FRM-078-12 01 Pre-Release-Autologous FMT Questionnaire 11. Have you taken any laxatives or anti-diarrhoea medication since stool storage?(Required) Yes No 12. Have you had any haemorrhoids, internal or external since stool storage?(Required) Yes No 13. Have you got any cold sores, anal fissures, anal ulcers, anal sores or pruritis ani since stool storage?(Required) Yes No 14. Have you had any gastrointestinal disease or signs of gastrointestinal disease since stool storage ? (e.g. nausea, vomiting, abdominal pain)?(Required) Yes No 15. Since stool storage, 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 specify16. 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 specify17. Have you had any metabolic conditions, including diabetes or obesity since stool storage?(Required) Yes No Document ID Version Title Page 4 of 8 TML-QA-FRM-078-12 01 Pre-Release-Autologous FMT Questionnaire 18. Have you had any systematic autoimmune conditions since stool storage?(Required) Yes No 19. Have you had you have any atopy since stool storage (e.g. asthma, eosinophilic disorders) ?(Required) Yes No 20. Have you had any neurological or psychiatric conditions since stool storage?(Required) Yes No 21. Since stool storage, have you ever been diagnosed by a clinician (e.g. physician or psychologist) with any of the following?(Required) Not Applicable Depression Anxiety (e.g. Generalised anxiety disorder) Bipolar disorder Schizophrenia Eating disorder Other (please specify) If Other, please specify:22. Have you had chronic pain syndromes, including chronic fatigue syndrome, Myalgic encephalomyelitis or fibromyalgia since stool storage?(Required) Yes No 23. Have you used any illicit or recreational drugs since stool storage ?(Required) Yes No 24. Have you had any malignant diseases since stool storage?(Required) Yes No 25. Have you had growth hormone, insulin from cows, or clotting factor concentrates since stool storage?(Required) Yes No Document ID Version Title Page 5 of 8 TML-QA-FRM-078-12 01 Pre-Release-Autologous FMT Questionnaire 26. Have you received an experimental medicine or vaccine since stool storage?(Required) Yes No If yes, please provide details:27. Have you received a live attenuated virus since stool storage?(Required) Yes No If yes, please provide details:28. Have you suffered from anorexia nervosa, bulimia, or any other eating disorder since stool storage?(Required) Yes No 29. Have you been prescribed any medication since stool storage?(Required) Yes No If yes, please provide details:30. Since donation have you suffered any infectious illness?(Required) Yes No If yes, please provide details:31. Since donation have you received a positive test result for any infection?(Required) Yes No If yes, please provide details:32. Have you taken part in unprotected sex (outside a primary monogamous relationship), had any kind of STD or participated in homosexual intimate contact since stool storage?(Required) Yes No Document ID Version Title Page 6 of 8 TML-QA-FRM-078-12 01 Pre-Release-Autologous FMT Questionnaire 33. Since stool storage, have you 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 34. Have you been involved in work as a sex worker or used the services of a sex worker since stool storage?(Required) Yes No 35. Have you had sex with somebody that was diagnosed with HTLV-1 and 2 since stool storage?(Required) Yes No 36. Have you had a new sexual partner or multiple sexual partners since stool storage?(Required) Yes No 37. Have you received antifungal medication?(Required) Yes No If yes, please provide details:38. Since stool storage, have you ever received antiviral medication?(Required) Yes No If yes, please provide details:39. Are you being followed by any medical specialists for any conditions at the moment?(Required) Yes No If yes, please provide details:40. For Female Donors: Are you currently pregnant?(Required) Yes No Document ID Version Title Page 7 of 8 TML-QA-FRM-078-12 01 Pre-Release-Autologous FMT Questionnaire 41. For Female Donors: Since stool storage, have you had any abnormal pap smear results?(Required) Yes No If yes, please provide details:42. Have you suffered from depression since stool storage ?(Required) Yes No 43. Are there any lifestyle factors you engage in that could put you at risk for infection since stool storage?(Required) Yes No If yes, please provide details:44. Have you spent more than 72 hours in prison for any reason since stool storage ? (including volunteering outreach programs, teaching capacity etc.)?(Required) Yes No I confirm that: • The information provided is complete and accurate to the best of my knowledge. • I understand that inaccurate or incomplete information may affect the suitability of the autologous FMT product for release. • I agree that the Medical Director and Quality team may review this information when determining product suitability. Patient Signature: ______________________ Thank you for completing this questionnaire. Document ID Version Title Page 8 of 8 TML-QA-FRM-078-12 01 Pre-Release-Autologous FMT Questionnaire Justification (N/A if not applicable): Activity Status (Pass/Fail) Signature & Date Production Supervisor/Manager Quality Assurance
