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Missouri Arthritis Rehabilitation Research and Training Center
University of Missouri-Columbia
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Funding Provided
by NIDRR

Project 5 Questionnaire

NOTE: Please review the technical requirements to take these classes.

First Name
Middle Name
Last Name
Address
Phone
E-mail


Please answer each of the following questions.


1. If you have arthritis, what is your diagnosis? (Check all that apply.)  Rheumatoid Arthritis
 Osteoarthritis
 Fibromyalgia
 Other  
2. Are you a caregiver to someone who has arthritis?  Yes    No
3. Are you a medical professional?  Yes    No
4. If "Yes," check the profession where you spend the majority of your time.  Physician
 Physical Therapist
 Occupational Therapist
 Nurse
 Other  
5. Why are you interested in taking this course? (Check all that apply.)  I want to improve my decision making ability related to potential treatment for arthritis.
 I wish to be part of a research team (Participatory Action Research partner)
 I would like to be involved in reviewing proposals written to obtain funds for research projects.
 Other  
6. Gender  Male    Female
7. Age Group  40 and under
 40-50
 51-60
 61-70
 Over 70  
 
  

 
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Copyright © 2004 The Curators of the University of Missouri  •  Revised: 17 Jun. 2005.  •  Comments?