Gut Microbiome Project

E-mail

Phone

Your Address

Weight (kg)

Number of Family Members

Your Sex

Select Male Female

What is your ethnicity?

Select Bengali Marma Chakma Santal Garo Tripuri Meitei Bihari Mru Rohingya

What type of toilet you use?

Select Low Commode High Commode

How many times a day do you defecate?

Your medical history of last 3 months. Write down the names of the medicines you have taken or are still taking in the last 3 months. Write down if there is any kind of operation

If you have taken a high dose of antibiotic / pain killer in the last 3 months, be sure to write down why you took it

Have you had any gastrointestinal surgery?

Select Yes No

What kind of probiotic foods have you eaten in the last 2 weeks? (Probiotic foods are made of good live bacteria and/or yeasts that naturally live in your body) (Multiple options are permitted)

Bananas Pickles Raw garlic Raw onions Buttermilk Yogurt Cheese দ Apple Dark chocolate milk

What are your daily eating habits (what kind of food do you eat most for breakfast, lunch, and dinner)? (Multiple options are permitted)

What do you usually eat for breakfast?

Rice Atta Roti khichuri Bread Fish Meat Chicken Vegetables Dal Egg

What do you usually eat for Launch?

Rice Atta Roti khichuri Bread Fish Meat Chicken Vegetables Dal Egg

What do you usually eat for dinner?

Rice Atta Roti khichuri Bread Fish Meat Chicken Vegetables Dal Egg

What kind of food is more in your daily diet?

Select Vegetables Fish Meat

Do you have any kind of processed food in your daily diet?(Processed food is a food item that has undergone multiple mechanical or chemical processing to change or preserve the test. (Multiple options are permitted)

pizza burgers cakes biscuits bacon fun snacks pastries ketchup Flavored nuts

Have you had diarrhea in the last one month?

Select Yes No

Do you smoke?

Select Yes No

How long have you been smoking?

Do you drink alcohol?

Select Yes No

How long have you been drinking alcohol?

In the list below, select which disease you have?

Select Colon Cancer Inflammatory Bowel Disease (IBD) Irritable Bowel Syndrome (IBS) Gastroesophageal reflux disease (GERD) Peptic Ulcer Disease (PUD) and Gastritis Gluten Sensitivity and Celiac Disease Constipation Hemorrhoids Diverticular Disease Diabetes Hypertension Allergy Asthma Coronary heart disease None

Have you had any cancer before?

Select Yes No

Have you been diagnosed with colon cancer? Please mention the date of diagnosis?

The type of colon cancer you have diagnosed?

The stage of colon cancer you have diagnosed?

Are you currently receiving treatment in a hospital or at home?

Select Hospital Home

How long have you been hospitalized after being diagnosed

We will take your medical details. Would you agree?

Select Yes No

Have you had any chemotherapy before?

Select Yes No

If you have a pet in your house, write the name of that animal-

What kind of water do you drink?

Select Tubewell Boiled Water Filtered water

Do you travel often? Do you eat local food of your travelled destination? Please mention the names of the foods you consume when you travel.