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Maine Older Adult Research Registry Profile Form
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* Indicates required question
I understand that my participation in the registry is voluntary and that I can change my mind and withdraw at any time.
*
Yes
I understand that by agreeing to participate, I will be contacted by the registry to update or correct my registry information regularly (approximately once a year).
Yes
Clear selection
I understand that the Center on Aging will not provide my contact information to a third party without my approval.
Yes
Clear selection
Please type your name as your signature
*
Your answer
Please type today's date
*
MM
/
DD
/
YYYY
Your first name
*
Your answer
Your last name
*
Your answer
Date of birth
*
MM
/
DD
/
YYYY
Street address
Your answer
City
Your answer
State
Your answer
Zip
Your answer
County
Your answer
Phone (Home)
Your answer
Phone (Cell)
Your answer
E-mail address
Your answer
I would like to be contacted by (Check all that apply)
*
E-mail
Mail
Phone
Voicemail
Required
Best time to reach you by phone if needed? (Check all that apply)
*
Morning (8am-12pm)
Afternoon (12pm-4pm)
Evening (4pm on)
Required
Registry Profile Information
The following information will be used to match you with studies that may be of interest to you. Please tell us more about yourself by marking the responses that best describe you.
Gender (Check one)
Male
Female
Another gender (Please specify below)):
Clear selection
If you selected "another gender" please specify
Your answer
Race (Circle one)
White/Caucasian
Black/African American
Asian
Another race (Please specify below):
Clear selection
If you selected "another race" please specify
Your answer
Are you Hispanic or Latino?
Yes
No
Clear selection
What is the highest degree or level of school you have completed? (Check one)
Eighth grade or less
Some high school
High school graduate or GED
Some college courses
Associate's or vocational degree
Four-year college degree
Some graduate school
Graduate degree
Clear selection
Who lives with you? (Check all that apply)
I live alone
Spouse/partner
Child
Grandchild
Non-relative
Other (please specify below)
If you checked "other" above, please specify who you live with.
Your answer
Where do you live?
Independently in own home or apartment
In an assisted living facility with my own apartment
In someone else’s home (with family member/friend)
Another living arrangement (please specify below):
Clear selection
If you checked off "other" for your living arrangement above, please specify:
Your answer
Has a doctor ever said that you have any of the following health conditions? (Check all that apply)
Arthritis
Asthma
Cancer
COPD
Chronic Pain
Depression
Diabetes
Heart Disease
High blood pressure
Memory loss
Migraines
Neuropathy
Obesity
Stroke
Osteoporosis
Other (specify below)
If you selected "other" above, please specify:
Your answer
Do you use any of the following assistive devices? (Check all that apply)
Standard cane
Walker
Braces
Crutches
Manual Wheelchair
Motorized Wheelchair
Scooter
Respirator/Oxygen
Service/Guide Animal
Other (specify below):
If you selected "other" above, please specify:
Your answer
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