RemissionBiome Self-Experiment Application
RemissionBiome is a self-experiment, supervised by healthcare providers.

Please fill out this application if you would like to be part of this community-science experiment. A few points about the form:
  1. You can save your progress and come back to it if you log in with Google. 
  2. It should take 3-5 minutes. 
  3. There's not a character limit for the "other" choices, so feel free to add as much info as you think is relevant, but it's also ok to keep the answers to just a few words.
  4. The cost of the protocol is $4000 USD /participant, but we are fundraising to supplement what people can pay, so don't let finances hold you back from applying.
  5. None of the answers to these questions are deal-breakers. They will just let us prioritize and plan for when people should start and how much prep they need to do.
  6. If you have questions, please email RemissionBiome@gmail.com.


Contribute to the GoFundMe. 

Thank you for your interest! We couldn't do this without the community support.

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E-mailadres *
Full name *
Is this your first time filling out this application or did you apply previously and filling it out again to answer the new questions? *
Twitter handle, LinkedIn, or other online presence
If you are accepted, who will you be willing to share your anonymized test results, symptom tracking data, demographics, etc., with? *
Which condition(s) do you have? *
Verplicht
How long have you been ill? *
How severe are you? *
Do you have a healthcare provider who can supervise you during the experiment? (As in, prescribing the antibiotics, ordering tests, and being available for any unexpected reactions.) *
How many months from now would you be able to start the prep part of the protocol? *
If you answered "4 or more months", please tell us more about your situation and when you think you would be able to start. 

(This is not a deal breaker, we just need to know for our planning. There will be future phases after the first 50 people, so it's still good to apply now.)
Do you have MCAS? *
If you do have MCAS, is it currently being treated? *
Do you have an autoimmune condition? *
If you do have an autoimmune condition, is it currently being treated? *
Which GI condition(s) do you have? *
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If you do have any GI conditions, are they currently being treated? *
Do you have any of these connective tissue issues?
Which RemissionBiome prep have you been doing?

(If you've been following Tamara's Tweets, you likely know about prep, but if not, it's ok. We'll continue to share information about it.)
 *
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Have you done any of these self-experiments?  *
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This question is not required, but if you would like to tell us more about your experiments, we are curious about aspects like:

What did you modify?
What did you track or measure to determine if it worked?
Do you have any of these trackers? *
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Which methods do you use for symptom tracking? *
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How much could you contribute toward doing your RemissionBiome self-experiment? 

The protocol costs ~$4000 per person for:
 - probiotics
 - supplements
 - safety testing beforehand
 - testing throughout the experiment to contribute to the science
 - testing afterwards while rebuilding the microbiome

We are fundraising to try to cover the cost that people can't afford in order to make the experiment accessible to everyone, but would like to get an idea of how much participants could cover. 

If you can contribute now to help us move even faster, please donate here: https://www.gofundme.com/f/Remissionbiome

(Amounts are in USD)
 *
Are you interested in volunteering?
Selectie wissen
Are you interested in volunteering in any of these specific areas?

(We are looking for those specific volunteers right now, but we would love to hear more about your skills, even if you don’t have skills in these particular areas.)

If you're interested in volunteering, we would love to hear more about your skills or how you think you could help.
Where do you live (Country, state, province, etc.)? *
Did you fill out the interest form for the Stanford at-home research study?

https://forms.gle/TDbBeoXDnqPL1kzb9
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Do you have any questions or comments for us? Any suggestions to improve this form?
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