Clostridioides difficile (C. diff) Trial Application

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Have you had any of the following: *

a) An admission to hospital for at least a 2-night stay in the last 12 months?
b) Attended Accident & Emergency two or more times in the last 12 months?
c) Had 10 or more hospital clinic or GP clinic visits in the last 12 months?
d) Received antibiotics (either by mouth or through a vein) for 2 or more days in the last 12 weeks?
e) Are you planned to stay in hospital for 2 or more nights, or do you have a date for elective surgery of any duration scheduled?

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Nearest Panthera Clinic *

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Do you consent to the collection and processing of your personal data in accordance with the GDPR for the purposes stated in our privacy policy?

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* To proceed with your pre-screening, we need your consent to collect and process your personal data in accordance with the GDPR. Without this consent, we cannot save your initial data or determine your eligibility, which would result in an incomplete application. Please select 'Yes' to consent. For more information or assistance, contact our team.

Are you aged 65 years or older? *

Have you had an admission to hospital for at least a 2-night stay in the last 12 months? *

In the last 12 months, have you been to Accident & Emergency two or more times? Please also count any hospital stay where you stayed just one night, as this can count towards the total *

In the last 12 months, have you had 10 or more appointments with a doctor, nurse or other healthcare professional? Please include GP surgery appointments, practice nurse or district nurse appointments, hospital outpatient and clinic appointments, blood tests, dressing clinics, physiotherapy and podiatry, at an NHS or private clinic. You can also count up to 3 telephone or video appointments. Please do not include pharmacy, dentist or mental health appointments. If you are not sure, please answer Yes and we will check with you. *

In the last 12 weeks, have you taken antibiotics by mouth, or been given antibiotics by injection or a drip, for 2 days or longer? *

Are you planned to stay in hospital for 2 or more nights, or do you have a date for elective surgery of any duration scheduled? *

Thinking about the last 3 years, have you needed a course of antibiotics lasting 2 days or more at least once in every one of those years? *

Has a doctor or nurse ever told you that you have any of the following? Please tick all that apply.

Kidney disease, sometimes called chronic kidney disease or CKD
Heart failure, sometimes called congestive heart failure
COPD, chronic bronchitis or emphysema
Bronchiectasis
Liver disease
Poor circulation, narrowed arteries or leg artery problems, sometimes called peripheral arterial disease. Please do not include varicose veins on their own
Diabetes where your blood sugar or HbA1c has been higher than your doctor would like over the last year
Two or more urine or water infections in the last 6 months, or three or more in the last year
Pneumonia or a chest infection treated with antibiotics in the last 6 months

Have you previously been diagnosed with an infection caused by C. diff (Clostridium difficile)? *

Have you had part of your small bowel or large bowel surgically removed? (Appendicectomy does not count.) *

Are you currently taking part in any other clinical trial where you receive regular medication? *

Do you take any medications you have been told suppress your immune system? e.g., anti-cancer drugs, radiotherapy. *

Have you been told you have a suppressed immune system? *

Clinic Phone or

Are you receiving dialysis, or have you been told you have end-stage renal disease? *