Microbiota Transplant Program - Peru

Microbiota Transplant Application

Complete the following sections to submit your pre-eligibility evaluation. All information is confidential and will be reviewed by our medical team.

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Patient Identification

Please provide your personal and contact information.

Full name *

Date of birth *

Sex *

M F Other

Address *

Phone *

Email *

For pediatric patients

Parent / Legal guardian name

Relationship

Primary treating physician

Referring physician (if different)

Primary Indication

Select your primary diagnosis or indication for Microbiota Transplant.

Recurrent Clostridioides difficile infection Severe/fulminant Clostridioides difficile infection Inflammatory bowel disease with recurrent C. difficile Ulcerative colitis (without C. difficile) Crohn's disease Irritable bowel syndrome Autism spectrum disorder Hepatic encephalopathy Multidrug-resistant organism decolonization Other

Other (please specify)

Tell Us About Your Condition

Please answer these questions specific to your selected diagnosis.

Number of documented C. difficile episodes

Diagnostic confirmation

Toxin positive PCR positive Both

Antibiotics used (check all that apply)

Vancomycin Fidaxomicin Metronidazole Bezlotoxumab

Failure after adequate treatment?

Yes No

Date of last antibiotic dose

Year of diagnosis

Disease extent

Proctitis (rectum only) Left-sided colitis Pancolitis (entire colon) Unknown

Current disease severity

Remission Mild Moderate Severe

Hospitalizations for ulcerative colitis flares

None 1–2 3 or more

Current medications for ulcerative colitis (check all that apply)

5-ASA / Mesalamine Corticosteroids Immunomodulators (azathioprine, 6-MP) Biologics (anti-TNF, vedolizumab, ustekinumab) JAK inhibitors (tofacitinib) None

Current symptoms (check all that apply)

Bloody stools Urgency Abdominal pain Frequent diarrhea (≥ 4 per day) Weight loss Fatigue

Year of diagnosis

Disease location

Ileal (small intestine) Colonic (large intestine) Ileocolonic (both) Upper gastrointestinal Unknown

Disease behavior

Inflammatory (non-stricturing, non-penetrating) Stricturing Penetrating (fistulizing) Unknown

Perianal disease?

Yes No

Previous surgeries related to Crohn's?

Yes No

If yes, please describe

Current medications for Crohn's (check all that apply)

5-ASA / Mesalamine Corticosteroids Immunomodulators (azathioprine, 6-MP, methotrexate) Biologics (anti-TNF, vedolizumab, ustekinumab) None

Current symptoms (check all that apply)

Chronic diarrhea Abdominal pain Weight loss Fistula or abscess Recurrent fever Fatigue

IBS subtype

IBS-D (diarrhea-predominant) IBS-C (constipation-predominant) IBS-M (mixed) IBS-U (unclassified)

How long have you had symptoms?

Less than 1 year 1–3 years 3–5 years More than 5 years

Current symptom severity

Mild (manageable, minimal impact) Moderate (affects daily life) Severe (significantly limits activities)

Have you been tested for C. difficile?

Yes No

Treatments previously tried (check all that apply)

Dietary changes (low FODMAP, etc.) Probiotics Antispasmodics Low-dose antidepressants (for gut function) Fiber supplements Antibiotics (rifaximin) None

Known triggers (check all that apply)

Stress Certain foods After an infection (post-infectious) No clear triggers

Age at autism diagnosis

Current support level

Level 1 (requiring support) Level 2 (requiring substantial support) Level 3 (requiring very substantial support)

Communication level

Verbal Limited verbal Non-verbal

Gastrointestinal symptoms (check all that apply)

Chronic constipation Chronic diarrhea Abdominal pain or discomfort Bloating Food selectivity / restricted diet Gastroesophageal reflux No gastrointestinal symptoms

Special diets tried (check all that apply)

Gluten-free / Casein-free Specific Carbohydrate Diet Ketogenic diet None

Current therapies (check all that apply)

Applied Behavior Analysis (ABA) Speech therapy Occupational therapy Behavioral medications Other

Please specify other therapies

Underlying liver disease cause

Alcohol-related Hepatitis B Hepatitis C Non-alcoholic fatty liver disease (NAFLD/NASH) Autoimmune hepatitis Other

Child-Pugh class (if known)

Class A (well-compensated) Class B (significant compromise) Class C (decompensated) Unknown

Number of encephalopathy episodes

Hospitalizations for encephalopathy episodes

None 1–2 3 or more

Current treatment for encephalopathy (check all that apply)

Lactulose Rifaximin Both (lactulose + rifaximin) None

Current complications (check all that apply)

Ascites Esophageal varices Portal hypertension None

Being evaluated for liver transplant?

Yes No

Type of resistant organism

Vancomycin-Resistant Enterococcus (VRE) Extended-Spectrum Beta-Lactamase producing (ESBL) Carbapenem-Resistant Enterobacteriaceae (CRE) Methicillin-Resistant Staphylococcus aureus (MRSA) Other

Site of colonization or infection

Gastrointestinal Urinary tract Bloodstream Wound / Skin Respiratory tract Other

Specify organism

How long have you been colonized or infected?

Less than 3 months 3–6 months 6–12 months More than 12 months

Previous decolonization attempts?

Yes No

Reason for seeking decolonization

Upcoming surgery Transplant evaluation Recurrent infections Other

Date of most recent positive culture

Medical History

Please indicate your relevant medical history.

Gastrointestinal History

Inflammatory bowel disease Colon cancer Recent gastrointestinal surgery (< 3 months) Ileus Toxic megacolon Gastrointestinal bleeding

Immune Status

Solid organ transplant Bone marrow transplant HIV Neutropenia Primary immunodeficiency Chronic corticosteroids (> 20 mg/day prednisone equivalent) Biologics (anti-TNF or similar) Chemotherapy

Other Comorbidities

Severe liver disease Chronic kidney disease on dialysis Uncontrolled diabetes Severe heart disease Pregnancy Sepsis Intensive care unit admission

Additional Medical Information

Please let us know if any of the following currently apply to you. This helps our team prepare the best care plan for you.

Hemodynamic instability Active gastrointestinal perforation Bowel obstruction Severe neutropenia (very low white blood cell count) Uncontrolled bacteremia Refusal to sign informed consent Unable to attend clinical follow-up

Current Medications

List all current medications including antibiotics, biologics, probiotics, and others.

Pre-Procedure Evaluation

Indicate which recent laboratory tests you have available.

Lab results must be within the last 14 days.

Recent labs (≤ 14 days)

Complete blood count Metabolic panel C-reactive protein Coagulation profile Stool test for dysbiosis (gut microbiome analysis)

Application Submitted Successfully

Thank you for completing the Microbiota Transplant pre-eligibility form. Our medical team will review your application and contact you within 48-72 hours.

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