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Patient perceptions of FMT acceptibility Supplementary: Research Instrument Survey If you are at least 18 years old and have a working knowledge of English, please consider filling out this survey 1 Patient perceptions of FMT acceptibility Thank you for participating in our study. This is a research project designed to study the attitudes of patients to a certain medical therapy offered by Gastroenterologists. The survey is completely optional, and is anonymous. Choosing to participate in the survey in no way affects your relationship with your doctor, the medical center, or any care you will receive. Feel free to leave any questions blank that may cause you anxiety or stress. If you have any questions feel free to ask the staff. 2 Patient perceptions of FMT acceptibility Demographics: 1. What is your age? ____ 2. What is your primary language? English French Spanish Arabic Chinese or Chinese dialects Russian Polish Haitian Creole Bengali Korean If other, please specify __________________ 3. Gender: Male Female 4. What is your current marital status? Married Widowed Divorced Separated Single 5. Do you have any children? Yes No 6. What is your racial background? Asian Black or African American Caucasian/White If mixed/other, please specify_______________ 7. Are you Hispanic or Latino (A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race)? Yes, Hispanic or Latino No, not Hispanic or Latino 8. Please select highest level of school completed: Less than high school High school graduate Vocational school College Graduate School 3 Patient perceptions of FMT acceptibility 9. Have you ever worked as a (check all that apply): Physician Other licensed healthcare professional (nurse, dentist, etc.) Non-licensed allied health assistant (home health aide, etc.) Scientist or researcher None of the above 10. What is your employment status (check all that apply)? Employed Student Self-employed Retired Unemployed Unable to work/disabled 11. What is your total household income? Less than $25,000 $25,000 to $49,999 $50,000 to $74,999 $75,000 to $99,999 $100,000 or more 12. What is your current living situation? Living independently or with spouse/partner Living at home with assistance (professional or family) Skilled nursing facility (i.e. nursing home) or assisted living 13. Do you take or have you taken any herbal medications (For example:. St. John’s Wort, Ginkgo biloba, Chinese herbals, Echinacea, Valerian, Saw Palmetto, etc.)? Yes No 14. Have you ever tried any of the following alternative therapies (Select all applicable)? Acupuncture/Acupressure Ayurvedic medicine Colonics Chiropractic Homeopathy Traditional Chinese Medicine None of the above If other, please list______________ 4 Patient perceptions of FMT acceptibility 15. How many bowel movements do you typically have in a day? _____________ 16. Have you ever or are you currently taking a product labeled as a probiotic? Yes No If yes, please answer the following questions. Otherwise skip to question 16: a. When did you take the probiotics (check all that apply)? Within the past 6 months 2-5 years ago 6 months to 1-year ago 6-10 years ago 1-2 years ago 10+ years ago b. Why did you take the probiotics? (check all that apply) To treat diarrhea To treat abdominal discomfort To treat constipation To promote overall health If other, please specify____________ c. What formulation of probiotics have you used (check all that apply)? Pills Yogurt (i.e Activia, Danactive) Powder/Sachet If other, please specify____________ 17. Have you ever been treated for chronic diarrhea (Episode of loose stools lasting four weeks or longer)? Yes No If yes, then please answer the following questions. Otherwise, skip to question 17: a. How long did the episode of diarrhea last? ________________ b. During the chronic diarrhea, would you ever have to wake up in the middle of the night because of diarrhea? Yes No c. During the chronic diarrhea, did you ever have any episodes of fecal incontinence? Yes No d. During the chronic diarrhea, how many times would you have a bowel movement a day? 1-3 3-6 7-10 10+ 5 Patient perceptions of FMT acceptibility e. How were you treated (Check all that apply)? Antibiotics Anti-diarrheals Probiotics If other, please describe_______________ f. Were you cured? Yes No 18. Have you heard of Clostridium difficile (C. diff) colitis? Yes No 19. Have you ever been treated for Clostridium difficile (C. diff) colitis? Yes No If yes, then please answer the following questions: a. When were you treated? Less than 6 months ago 2-5 years ago 6 months to 2 years ago 6-10 years ago b. Did you take any of the following antibiotics? Vancomycin (Vancocin) Metronidazole (Flagyl) Fidaxomicin (Dificid) None of the above c. Was your diarrhea cured permanently? Yes No d. Did you ever have Clostridium difficile again? Yes No 20. Do you have a friend or relative who has been treated for Clostridium difficile (C. diff) colitis? Yes No If yes, were they cured permanently? Yes No 6 Patient perceptions of FMT acceptibility 21. Have you ever been diagnosed by a physician with any of the following (Please select all that apply)? Diabetes Gastrointestinal reflux disease Human Immunodeficiency Virus (HIV) Ulcerative Colitis Crohn’s Disease Irritable Bowel Syndrome (IBS/spastic colon) Microscopic Colitis Pancreatic Insufficiency Colon Cancer 22. Please list any other medical problems: 23. Have you had any prior surgeries? Yes No 24. Have you had an intestinal surgery? Yes No 25. Have you ever had an ostomy (a surgically created connection between the intestines and the skin, where stool is collected in a bag attached to the skin)? Yes No 26. Please list any surgeries you had and the reason for the surgery: Please continue the survey, thank you for your participation. 7 Patient perceptions of FMT acceptibility The following are descriptions of common medical procedures performed and sometimes recommended by gastroenterologists: Colonoscopy During a colonoscopy, a long, flexible tube is inserted into the rectum and a tiny camera at the tip allows the doctor to view the inside of the colon. To prepare for the procedure, a patient may be asked to take a strong laxative to empty the bowels. Most patients are given a sedative or anesthesia to help them relax or sleep during the colonoscopy. The risks of the procedure include the risks of allergy or altered vital signs with the anesthesia. There is a small (1 in 10,000) risk of bleeding, infection, or perforation (an accidental tear in the intestines) from the colonoscopy. Nasogastric Tube A narrow plastic tube is passed through the nose, down the food pipe, and into the stomach. No anesthesia is given for this procedure. There is typically some discomfort or gagging and a small risk of pneumonia with this procedure. Enema Liquids are introduced into the rectum and colon through the anus. The patient must try to hold in the liquids and not pass any stool for a few hours in order to help the therapy work. No anesthesia is given for this procedure. There is a risk of discomfort from the procedure and a very small risk of perforation (less than 1 in 1000). 1. Prior to this survey, have you ever had any of the following procedures? (check all that apply) Colonoscopy Enema Nasogastric tube Clostridium difficile are bacteria that can infect the colon. This infection can cause severe abdominal pain, diarrhea, and very rarely organ failure and death. This infection is typically treated with two weeks of antibiotics taken by mouth. Sometimes the antibiotics will not work at all, or will work but the infection comes back. A new therapy called stool transplant is now available that works in a different way. It involves taking the stool of a healthy person, mixing it with water, and placing a small amount of the mixture into the colon of a sick person. Instead of killing the “bad” Clostridium difficile bacteria with antibiotics, a stool transplant instead is performed to give a sick person “good” bacteria to rid them of Clostridium difficile. Donor stools are screening to make sure there are no known infectious agents. Stool transplants are safe and effective, although the long-term effects are still not known. 1. Prior to this survey, had you ever heard of a stool transplant? Yes No 2. If you had an infection in your colon that was causing diarrhea, would you take antibiotics? 8 Patient perceptions of FMT acceptibility Yes No 3. If you were told that your risk of dying from an infection was low (1-5%), would you consider a stool transplant for a cure? Yes No 4. If you were told that your risk of dying from an infection was moderate (50%), would you consider a stool transplant for a cure? Yes No 5. If you were told that your risk of dying from an infection was high (greater than 90%), would you consider a stool transplant for a cure? Yes No 6. If your doctor recommended a stool transplant as treatment for your infection, would you agree to one? Yes No 7. What about a stool transplant would make you not want the procedure (check all that apply)? Dirty/unsanitary Transmission of disease Embarrassment Do not want invasive procedure Afraid of procedure Do not think it would be successful Believe procedure is unsafe If other, please describe: __________________ 8. If you are willing to undergo a stool transplant, please rank your preference for the method of delivery. (1 = most preferred, 3 = least preferred) 1 2 3 Colonoscopy (1-2 treatments) Enema (5-6 treatments) Nasogastric tube (1-2 treatments) I would not accept a stool transplant by any delivery method Thank you for taking time to complete our survey. 9
