Questionnaire

    Kindly provide the order number* of the purchased kit
    *Your order number can be found on the confirmation email you received when purchasing your kit.

    Kindly tick the option that refers to you:
    I am…

    Consent to personal data (Mandatory)

    i. I have been fully informed about the gut microbiome test (and any additional related test), including its purpose, procedure, limitations, costs, and the implications of the results.
    ii. I acknowledge that the test results are not a substitute for a medical diagnosis and that The BioArte does not take responsibility for the use of the results by me or my clinician and any consequences thereof.
    iii. I confirm that the personal and medical information I have provided is accurate and truthful. I understand that the clinical team may contact me for additional information, which may be used for result interpretation purposes. I agree that the test report may be forwarded to my clinician for appropriate advice.
    iv. I agree to provide a biological sample and consent to its shipping to The BioArte facilities for testing and analysis.
    v. I consent to the collection, storage, and processing of my personal data, including health-related information. I understand that my data will be used solely for the purposes of conducting the gut microbiome test and providing me with the results. I am aware that my identifiable data will not be shared with third parties without my explicit consent, except as required by law.
    vi. I consent to receiving the test report via email to the address provided in the below contact information.

    Consent for research purposes (Optional)

    I acknowledge that my Personal (Health) Data and remaining sample could contribute to further research, development, and enhancement of diagnostic techniques and potential therapeutic remedies. I consent to The BioArte's storage once pseudo anonymized, of:

    • My Personal (Health) Data and analytical results.

    • Both original and processed sample

    and that it will be kept by The BioArte for a minimum period of 10 years.

    The company will use this data, along with the remaining samples that have been pseudonymized, for scientific research (both internally and externally) as well as for commercial research in the field of related to the human microbiome. The aim is to gain a better understanding of the microbiome's role in an individual's overall health and susceptibility to diseases, as well as their potential response to treatments. Consent can be revoked at any time as explained below.
    Public and private healthcare institutions, bio-medical companies worldwide, can be granted access to the patient’s pseudonymized data for research purposes, with the relevant guarantees adopted to ensure legitimacy of the data transfer (especially if the recipient is in a non-EEA country).
    Please visit www.thebioarte.com or contact [email protected] for updated information on the research projects in which your pseudonymised data may be used.

    Please visit Data Privacy to consult our data privacy policy.

    HAVING READ AND UNDERSTOOD THE INFORMATION ABOVE, I CONFIRM THAT:
    i. I have read and understood the indication, purpose, characteristics, scope, procedure, success rate, complications, limitations, and economic cost of this test, and have had the opportunity to ask questions and any questions that I had were answered fully and to my satisfaction. I have also been given information on the implications of the test results, any possible follow up and where applicable, any further tests that might be required. I am aware that clinical and technical staff will be at my disposal for any questions or additional counselling that I may require once the results of the test are known.
    ii. I understand that the results of this test are not a substitute to a medical diagnosis performed in a clinical setting provided by a healthcare professional. I accept that The BioArte does not take responsibility for the use, by me or my clinician, of the results obtained and any consequences of such use.
    iii. I confirm that the information I have given, both personal and medical, is accurate and truthful. I acknowledge that the clinical team may reach out to me for additional clinical information, which may include details required for research purposes.
    iv. In view of the complexity of the tests, results should be assessed alongside other clinical information by healthcare professionals. Consequently, I agree that the test report may be forwarded to the requesting clinician so that I can be offered the most appropriate advice.
    v. I am not receiving any compensation as the participant nor will I be owed any funds, at this moment or in the future, due to any invention(s) resulting from research and development using my specimen(s).
    vi. I understand that the results of this study may be used for medical or scientific purposes, may be presented, for example, at meetings, in scientific publications, and that they may be reported or published; however, I shall not be personally identified in any way, either individually or collectively.
    vii. I have been informed that this informed consent can be withdrawn at any time.

    Sign the consent with full name and surname. If you are a relative or guardian of the person submitting the sample, kindly sign with your name and surname:

    Date of submission:

    Personal information

    Kindly provide the details of the person whose sample is being provided:

    Birth sex:

    Date of Birth:

    Contact information

    Provide the email address at which you wish to receive the test report.

    Test request information

    Sample type:

    Test type:

    What is the specific reason for undergoing gut health testing? (Multiple selection - Select as many options that refer to you)
    Ameliorate gastrointestinal functionMetabolic HealthEnhance mineral absorption (calcium - magnesium - iron)Glucose controlImprove carbohydrate and lipid metabolismWeight managementReduce InflammationImprove Immune System FunctionPersonalized NutritionSide effect of medicationSkin ConditionsMuscle recovery/anti-fatigueMaintain physical conditionImprove cognitive functionImprove mental statePrevent pre-term birthRebalance of a healthy vaginal microbiotaOther

    Medical and Nutritional Questionnaire

    Information on your medical history and any medication or issues you may be experiencing is crucial for the evaluation of your samples. The BioArte laboratory will analyze your samples, and our microbial expert will interpret the raw data together with the information you include in this form. This process allows the microbial expert to take into consideration your medical history and your current state when evaluating the results.

    Kindly answer the following questions about your medical history, nutrition, and current state of health.

    How would you describe your typical dietary patterns? (Select 1 option)

    How would you describe your typical water intake levels? (Select 1 option)

    Do you have any particular indication related to your body composition? (Optional)

    Body measurements

    What is the circumference of your waist?
    Measure the narrowest part of your waist, passing through the midpoint between the last rib and the iliac crest. (See image for reference 'a' portion)

    What is the circumference of your hips?
    Measure the widest part of your hips, approximately at the level of the greater trochanter. (See image for reference 'b' portion)

    Were there any notable factors during your birth that may impact your gut microbiome composition? (Multiple selection - Select as many options that refer to you)
    Mode of Delivery Vaginal BirthMode of Delivery Caesarean SectionBreastfeedingFormula FeedingPre-term BirthUnknown
    Do you have any known dietary or digestive health conditions ?

    Multiple selection - Select as many options that refer to you
    Food intoleranceLactose intolerance or sensitivityGluten intolerance or sensitivityDiscomfort when consuming LactuloseCow's milk allergyFood allergyNickel allergyOther

    Are there any specific gastrointestinal conditions or symptoms you are currently experiencing ?

    Multiple selection - Select as many options that refer to you
    Gastroesophageal Reflux Disease (GERD)EsophagitisPeptic UlcersBowel dysfunctionIrritable Bowel Syndrome (IBS)DiverticulitisGastroenteritisPancreatitisConstipationDiarrheaDyspepsiaBloatingAbdominal painFlatulenceStrainingIncomplete evacuationNecrotizing enterocolitisGaseous colicGastro-intestinal discomfortLeaky gutSmall intestinal bacterial overgrowth (SIBO)Other

    Are there any metabolic conditions or concerns you are aware of ?

    Multiple selection - Select as many options that refer to you
    Elevated blood glucose levelsInsulin sensitivityHigh Cholesterol LevelsHigh TriglyceridesType 1 DiabetesType 2 DiabetesOther

    Have you been diagnosed with any cardiovascular conditions ?

    Multiple selection - Select as many options that refer to you
    Hypertension (High Blood Pressure)AtherosclerosisCoronary artery diseasePostprandial lipemiaOther

    Do you have a history of neurological or mental health conditions ?

    Multiple selection - Select as many options that refer to you
    DepressionAnxietyStressAttention-deficit/hyperactivity disorder (ADHD)EpilepsyCognitive impairmentDyspraxia - Developmental co-ordination disorderPica syndromeAutism Spectrum Disorder (ASD)Parkinson’s diseaseMultiple sclerosisAlzheimer’s diseaseMajor depressive disorder (MDD)Sleep restrictionMemory problemsMyalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS)Anorexia nervosaOther

    Have you been diagnosed with any autoimmune or inflammatory conditions ?

    Multiple selection - Select as many options that refer to you
    Systemic Lupus Erythematosus (SLE)Celiac diseaseAnkylosing SpondyloarthritisRheumatoid ArthritisFacet Joint SyndromeInflammatory bowel disease (IBD)Hashimoto thyroiditis (chronic autoimmune thyroiditis)Other

    Do you have any dermatological conditions or skin-related concerns ?

    Multiple selection - Select as many options that refer to you
    PsoriasisDermatitisAtopic dermatitisDandruffAcneEczemaRosaceaLichen PlanusPruritus (Itchy Skin)Other

    Are you currently experiencing any musculoskeletal disorders or conditions ?

    Multiple selection - Select as many options that refer to you
    OsteoporosisFibromyalgiaMuscle damageOther

    Have you been diagnosed with any hepatic disorders or liver-related conditions ?

    Multiple selection - Select as many options that refer to you
    Non-alcoholic fatty liverHepatic encephalopathyNon-alcoholic steatohepatitisOther

    Are you experiencing any issues with your ears or hearing ?

    Multiple selection - Select as many options that refer to you
    OtitisOther

    Do you have any current oral health concerns or problems ?

    Multiple selection - Select as many options that refer to you
    Oral health problemsPeriodontal diseaseGeneralized gingivitisOral halitosisCariesOther

    Have you been diagnosed with any respiratory conditions ?

    Multiple selection - Select as many options that refer to you
    Allergic rhinitisAsthmaRhinoconjunctivitisEnvironmental allergiesUpper respiratory tract infectionOther

    Are you currently experiencing any gynaecological conditions or reproductive health concerns ?

    Multiple selection - Select as many options that refer to you
    Candida albicansNeisseria gonorrhea infectionTrichomonas vaginalis infectionEndometriosisIntrauterine adhesionHuman Papilloma VirusBacterial vaginosisVaginal health problemsStreptococcus vaginal infectionPregnancy gingivitisPolycystic Ovary Syndrome (PCOS)Menstrual DisordersMenopausal Hormonal ChangesOther

    Have you experienced any hormonal imbalances or disturbances ?

    Multiple selection - Select as many options that refer to you
    HypothyroidismHyperthyroidismReproductive Hormone DisordersLow ProgesteroneOther

    Are you currently experiencing any urinary tract disorders or issues ?

    Multiple selection - Select as many options that refer to you
    Urinary Tract Infections (UTIs)CystitisUrinary StonesUrinary IncontinenceOther

    Have you been diagnosed with any hematologic or genetic disorders ?

    Multiple selection - Select as many options that refer to you
    ThalassemiaOther

    Have you been diagnosed with any infectious diseases or conditions ?

    Multiple selection - Select as many options that refer to you
    Bacillus cereusCampylobacter jejuniClostridioides difficileClostridiumPathogensEscherichiaEscherichia coliHelicobacterHelicobacter piloriInfection post Hospitalization ICUKlebsiellaListeria monocytogenesProteus mirabilisRotavirusSepsis complicationsStreptococcusVibrio choleraeYersinia enterocoliticaBacteroides fragilisEnterobacter cloacaeEnterococcus faecalisEnterococcus faeciumKlebsiella pneumoniaePhocaeicola vulgatusPseudomonas aeruginosaSalmonella entericaListeria ivanoviiPoliovirusHIVSexual Transmitted InfectionsOther

    Have you received any diagnosis or treatment for oncological conditions ?

    Multiple selection - Select as many options that refer to you
    Breast CancerLung CancerColorectal CancerLeukemiaLymphomaProstate CancerPancreatic CancerOvarian CancerSkin CancerBrain TumorsOther

    Are you currently taking any medications or supplements?

    Multiple selection - Select as many options that refer to you
    Anti-acidsAntibioticRifaximin for diverticular diseaseChemotherapyProbioticsOther

    Do you have a family history of any relevancy to pathology?

    Do you engage in regular physical activity?

    Multiple selection - Select as many options that refer to you
    WalkingRunningSwimmingGym workoutsYogaDancingOther

    Additional information (Optional)

    Date of sample

    The tube has a sticker on it on which the sample collection date must be written. It is best to use a marker to write the date of when the sample was collected. If you have trouble writing the collection date on the tubes, you can take note of the date and place the date below:

    Date of Sample