Study Participant Questionnaire
Have you ever had HIV, Hepatitis B, or Hepatitis C? *
If you answered "Yes" to ever having HIV, Hepatitis B, or Hepatitis C, you do not qualify for this study. Please do not complete the remainder of the questionnaire. We thank you for your time and consideration.
How did you hear about us? *
Your answer
Name *
Your answer
Home Address *
Your answer
City and State *
Your answer
Zip Code *
Your answer
Phone *
Your answer
E-mail *
Your answer
Age *
Your answer
Gender *
I identify my ethnicity as: (select all that apply) *
Required
Weight
Your answer
Height
Your answer
Allergies
Your answer
Type of Cancer *
Your answer
What best describes your diet? *
Required
Do you currently smoke tobacco products?
If you smoke tobacco products, how many packs per day?
Your answer
Have you ever smoke tobacco products in the past?
If you have smoked tobacco products in the past, how long ago?
Your answer
Do you vape, or use e-cigarettes?
Do you use marijuana?
Do you drink alcoholic beverages?
If you drink alcoholic beverages, how many drinks on average per week?
Your answer
Do you drink caffeinated beverages?
If you drink caffeinated beverages, how many drinks on average per day?
Your answer
Past Medical History: Do you have a history of any of the following?
Do you have a history of autoimmune disease? Check any that apply:
Current Medications: Please list everything you are currently taking including prescription medicines, over-the-counter products, vitamins, and supplements.
Your answer
Have you taken any antibiotics in the past 12 months? *
If you have taken antibiotics in the past 12 months, please describe which antibiotics and what dates were they taken?
Your answer
Have you taken any probiotics in the past 12 months? *
If you have taken probiotics in the past 12 months, please describe which probiotics and what dates they were taken? (Examples of probiotics include: Culturelle, Align, Florastor, Lactobacillus, Saccharomyces boullardi, bifidobacterium)
Your answer
Do you have a family history of cancer? *
If you have history of cancer in your family, please provide relationship to you and type of cancer
Your answer
What type of cancer do you have? If you do not have a history of cancer, please reply "no cancer" and skip the remaining questions. If you have cancer or a history of cancer in the past, please continue to answer the questions below *
Your answer
Age at cancer diagnosis?
Your answer
Stage at cancer diagnosis?
Your answer
Date of initial scan?
Your answer
What type of cancer treatment(s) have you taken in the past?
Your answer
What type of cancer treatment are your currently receiving?
Your answer
Please provide us with date of treatment?
Your answer
What is your response to treatment? *
Required
What side effects did you experience from your treatment?
Have you experienced any immune related side effects?
Intestinal problems/colitis: Diarrhea, blood in stool, or tarry stool, or severe abdominal pain or tenderness?
Skin Rash / Dermatitis?
Lung problems / pneumonitis : Chest pain, new or worse cough, shortness of breath?
Liver problems / Hepatitis: Yellowing of the skin or whites of the eyes , pain on the right side of the stomach, dark colored urine, bleeding or bruising much more easily?
Kidney problems / Nephritis: Less frequent urination or blood in urine?
Brain / Encephalitis: Severe headaches, confusion, or changes in balance?
Thyroid problems / Endocrinopathy?
Blood sugar increases / Type 1 Diabetes?
Pituitary gland problems / hypophysitis
You may be eligible to continue the study. Please answer the following questions:
Are you currently receiving therapy for cancer?
Have you been in remission for the past 6 months or more?
If you answered yes to either question, would you be interested in continuing your participation in the study by donating up to one stool per month for 6 months, and then quarterly for up to 3 years?
We would like to send you a t-shirt, please indicate your shirt size below
Informed Consent to Participate in Clinical Research Study and Authorization to Use Your Private Health Information
Informed Consent to Participate in Clinical Research Study is made available for your review at

http://persephonebiome.io/informed-consent-to-participate-in-clinical-research-study/

Authorization to Use Your Private Health Information is made available for your review at

http://persephonebiome.io/authorization-to-use-your-private-health-information/

I agree to share my information as described in this form and I consent to be in the study *
Required
Type full name of study participant below *
Your answer
Today's Date *
MM
/
DD
/
YYYY
Thank you for your contribution and participation in our study! We appreciate your time and stool donation and wish you well.
Should you have any questions about this questionnaire, please contact support@persephonebiome.com or call (858) 682-4777
Submit
Never submit passwords through Google Forms.
This form was created inside of Persephone Biome.