LA CaTS Volunteer Research Registry

Volunteer Research Registry Form

If already registered, please login)

You may choose to supply as much or as little information on this form as you like. However the more information you give us, the better we can personally match you to one of our studies.

First Name:Last Name:

Address:
City:
State:ALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWYZip:

What is the best way to contact you?:
phone (day)phone (night)email
Phone (Day time):
Phone (Night Time):
Email:

Gender:FemaleMaleTransgender
Birth Year:19001901190219031904190519061907190819091910191119121913191419151916191719181919192019211922192319241925192619271928192919301931193219331934193519361937193819391940194119421943194419451946194719481949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021202220232024
Height Feet:012345678Inches:01234567891011
Weight (lbs):

Are you in good health, with no chronic medical conditions::Yes-I am in good health(without chronic medical conditions)No-I currently have a medical condition

Have you ever participated in a research study?:YesNo

Race:American Indian or Alaska nativeAsianBlack or African AmericanNative hawaiian or other Pacific IslanderHispanic or Latino White Multi-Racial
Do you use tobacco:YesNo
Are you a twin or triplet:YesNo
What is the highest level of eduction completed:Less than a high school diplomaHigh school graduateSome college (no degree)Associate degreeBachelor degreeMaster degreeProfessional degreeDoctoral degree

Please list the conditions or diseases a doctor has told you that you have. Click on all that apply. This information is optional, but providing it may help researchers match you with studies that fit you personally::

Allergies	HIV/AIDS Infections	Diabetes/Obesity
Ear/Nose/Throat	Cancer- all types	Head and Neck
Heart and Blood Vessels	Peripheral Vascular Disease	Congestive Heart Failure
Heart Attack	Mental Health and Addiction	Hepatitis Infection
Blood Pressure	Kidney Disease	Skin Diseases
Plastic Surgery	Women's Health	Stomach and Intestines
Blood Disorders	Children's Health	Eye Disease
Bone and Muscles	Arthritis and Joints	Stroke and Brain Disorders
Urinary Tract- Urology	Asthma/COPD- Lung Disease

Please list all medications (including over-the-counter drugs) that you are now taking::

Please list any additional health history information (diagnoses or conditions, hospitalizations, surgeries, etc.). This information is not required, but may help match you with studies that fit you personally.:

Input By:MyselfAssistant
User ID:
Password First:
Password Again:

Security Question #1:What high school did you graduate from?What town were you born in?What is your favorite movie?Who is your favorite male actor?Who is your favorite female actor?What is your favorite restaurant?Who is your favorite musician?What is the middle name of your youngest child?What school did you attend for sixth grade?What was the name of your first pet?What was your first car?Name of your favorite elementary school teacher?What is your oldest sibling's birthday month and year?Where did you meet your spouse/significant other?What was your childhood nickname?In what city or town did your mother and father meet?What was the name of your first stuffed animal?In what town was your first job?What city did you live in during the 3rd grade?First name of your childhood best friend?
Security Response #1:
Security Question #2:What high school did you graduate from?What town were you born in?What is your favorite movie?Who is your favorite male actor?Who is your favorite female actor?What is your favorite restaurant?Who is your favorite musician?What is the middle name of your youngest child?What school did you attend for sixth grade?What was the name of your first pet?What was your first car?Name of your favorite elementary school teacher?What is your oldest sibling's birthday month and year?Where did you meet your spouse/significant other?What was your childhood nickname?In what city or town did your mother and father meet?What was the name of your first stuffed animal?In what town was your first job?What city did you live in during the 3rd grade?First name of your childhood best friend?
Security Response #2: