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FMT TREATMENT – Questionnaire

Name(Required)
Address
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Diagnosed with: (Please tick appropriate box)
Irritable Bowel Syndrome

Inflammatory Bowel Diseases

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DD slash MM slash YYYY
Please select

Current Medications

Antibiotics
Anti-Inflammatories/Steroids
Biologics

Latest Pathologies (within 2 months)

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Have you had a Faecal Microbiota Transplant before?
Have you had any of the following procedures?
DD slash MM slash YYYY
DD slash MM slash YYYY
DD slash MM slash YYYY
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