Clostridioides Difficile Infection Clinical Trial Application

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Name *

Email *

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Date of Birth *

Address *

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Nearest Panthera Clinic *

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? *

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? *

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?

Have you had any of the following: *

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.) *

of of your

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? *

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