腸道微生物篩查表申請表 Stool Donor Application Form
*公告
由於捐贈計劃反應熱烈， 現階段申請名額已滿。如有興趣參加下一階段招募計劃，請填寫以下簡單申請表，請填寫正確的email, 儲存我們的WhatsApp號碼作為聯絡人之一，以便接收日後重啟計劃的訊息。（中文大學腸胃科WhatsApp號碼：6582 2158）
也請簡單在下面留下個人資料，方便日後我們主動聯絡你（敬請留意E-mail和WhatsApp訊息），所有資料只供香港中文大學研究之用。中文大學對申請者的篩選有最終決定權。謝謝你們的支持！
*Notice
The quota has been full for registration for the Stool Donation Program. If wished to register for the program in the next stage, kindly complete the application form below. Provide us your email and save our WhatsApp number in your contact list for our future notification regarding the reopening of the application. (CUHK GI team WhatsApp number: 6582 2158)
Kindly leave your personal contact information below for us to contact you in the future (Email OR WhatsApp messages). All data collected will be solely used by CUHK for research purpose. Should you have any enquiries, feel free to contact us via WhatsApp. CUHK has the sole discretion to determine applicants' eligibility for stool donation. Thank you for your support!
*公告
由於捐贈計劃反應熱烈， 現階段申請名額已滿。如有興趣參加下一階段招募計劃，請填寫以下簡單申請表，請填寫正確的email, 儲存我們的WhatsApp號碼作為聯絡人之一，以便接收日後重啟計劃的訊息。（中文大學腸胃科WhatsApp號碼：6315 6634）
也請簡單在下面留下個人資料，方便日後我們主動聯絡你（敬請留意E-mail和WhatsApp訊息），所有資料只供香港中文大學研究之用。中文大學對申請者的篩選有最終決定權。謝謝你們的支持！
*Notice
The quota has been full for registration for the Stool Donation Program. If wished to register for the program in the next stage, kindly complete the application form below. Provide us your email and save our WhatsApp number in your contact list for our future notification regarding the reopening of the application. (CUHK GI team WhatsApp number: 6315 6634)
Kindly leave your personal contact information below for us to contact you in the future (Email OR WhatsApp messages). All data collected will be solely used by CUHK for research purpose. Should you have any enquiries, feel free to contact us via WhatsApp. CUHK has the sole discretion to determine applicants' eligibility for stool donation. Thank you for your support!
簡單篩查 Screener
請簡單填寫以下篩查問卷。謝謝。
Kindly fill in the screening questionnaire below. Thank you.
1. 出生日期 Date of Birth
1. 出生日期 Date of Birth
*
/
DD
/
MM
YYYY
2. 年齡 Age
*
3. 身體質量指數 Body Mass Index (BMI)
計算方法=體重（公斤）÷身高（米）÷身高（米）
Calculation = Body weight (kg) ÷ Body height(m）÷ body height(m）
*
3. 身體質量指數 Body Mass Index (BMI)
計算方法=體重（公斤）÷身高（米）÷身高（米）
Calculation = Body weight (kg) ÷ Body height(m）÷ body height(m）
<18
18-25
25-30
不清楚 Not sure
4. 你是否定期服用藥物 (定義為需要服用三個月以上的藥物)?
Are you taking medication regularly (defined as a need to take drug more than three months)?
*
4. 你是否定期服用藥物 (定義為需要服用三個月以上的藥物)?
Are you taking medication regularly (defined as a need to take drug more than three months)?
是 Yes
否 No
個人資料 Personal Information
姓名 Name
*
聯絡電話 Contact number （日後用於致電和WhatsApp訊息) (For calling AND Whatsapp messages)
*
電郵 Email (敬請正確填寫 Type correctly please)
*
電郵 Email (再次核實)(re-enter)
*
FAQs 常見問題:
Q1. 大便捐贈的重要性為何？
What is the importance of stool donation?
很多疾病都和腸道微生物失調有關。一些俗稱好菌的活性微生物能於健康人士的大便中找到。這些好細菌在身體裏進行代謝，不但能保持大腸粘膜上皮完整，同時也提高宿主的免疫系統。透過腸道微生物移植，有需要的病人可以從中獲得這些對健康有裨益的好細菌。 Many diseases are associated with an imbalanced profile of gut microbiota. There are a lot of live microorganisms, as known as good bacteria, in stool samples from healthy people. Not only the integrity of the cell lining of the gut walls can be improved by these good bacteria, the immunity of the host can also be enhanced through the metabolism of these microbes. Through Intestinal microbiota transplant (IMT), patients in need could benefit from the transfer of these health-promoting bacteria.
Q2. 我對是次計劃有興趣，該如何申請大便捐贈計劃？計劃對申請者的篩查步驟為何？
I am interested in the program. How should I apply for the Stool Donation Program? What are the steps of the screening process?
簡單填寫以下初步篩查問卷和留下個人資料。合資格的申請者將進行更詳細的健康問卷，血液和大便樣本測試。 Simply complete the screener and leave your contact below. Eligible applicants will be screened through health screening questionnaire, blood test and stool test.
Q3. 若成為定期大便捐贈者，日後如何進行捐贈? 獎勵會如何計算？
How do I donate stool if I become a qualified regular donor? How will the reward be determined?
捐贈者除了可親臨威爾斯親王醫院指定的洗手間即場提供大便樣本，也可自行在舒適的環境中預備樣本並於2小時內回醫院提交樣本。獎勵的計算將視乎捐贈者的捐贈次數、大便樣本的質素和重量而定。 Donors can either leave their stool sample on the spot in an indicated toilet in Prince of Wale’s Hospital, OR prepare their stool samples in their comfortable setting and return the samples within 2 hours of defecation. The reward depends on the frequency, quality and the total weight of donor’s stool donation.
Q4. 捐贈大便期間有飲食上的建議或限制嗎？
Is there any dietary advice or restriction when donating stools?
能夠提供優良的內在環境予腸道細菌茁壯成長非常重要。雖然計劃本身並未有執行嚴謹的飲食限制，我們鼓勵大家日常多進食原型食物，而取代不必要的加工食物，原因在於我們知道好些食物添加劑能夠破壞腸道微生物平衡。此外，結構較複雜的碳水化合物亦能促進好菌成長。至於營養補充品方面，大便捐贈者將需暫停任何服用當中的益生菌。 It is most important to provide a suitable internal environment for the gut bacteria to thrive. While the program per se will not apply strict dietary restriction on applicants, we do encourage stool donors, on a regular basis, consume whole foods in replacement of processed food as certain food additives are proposed to distort the profile of gut microbiota. Intake of carbohydrate with complex structure also favours fermentation of good bacteria. In terms of supplements, however, commercial probiotics are not allowed after becoming stool donors.
Disclaimer
The personal data collected will be used by Division of Gastroenterology & Hepatology and authorised personnel for processing the captioned purposes in accordance with relevant provisions of the Personal Data (Privacy) Ordinance.