What company are you screening for?
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Poudre School District
Thompson School District
Weld School District
Evre Woman's Health and Wellness
Other (ex. Community Event/Health Fair/Worksite Wellness)
Poudre School District
Thompson School District
Weld School District
Evre Woman's Health and Wellness
Other (ex. Community Event/Health Fair/Worksite Wellness)
First Name
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Last Name
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Date of Birth
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M-D-Y
Sex Assigned at Birth
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Male
Female
Sex assigned at birth is needed to calculate screening results.
Click here if you identify with a sex different than the one assigned at birth.
Click here if you identify with a sex different than the one assigned at birth.
Email
Note: You will receive a notification email when your screening has been completed.
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Your results will be entered into EPIC (electronic medical records used by UCHealth, Associates of Family Medicine, etc.) to be viewable by your physician or self in MyHealthConnection.
Check if you are:
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Benefited employee
Benefited family member
Neither (not on PSD insurance, will self-pay)
Benefited employee
Benefited family member
Neither (not on PSD insurance, will self-pay)
Insurance ID #
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PSD has made this a required field this year. If you are a new-hire, please type "new hire"
Employee ID #
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Are you participating in the onsite flu-shot clinic?
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Yes
No
NOTE: Flu shots not offered at every screening site
Is the first time you are receiving the flu vaccine?
If yes, you are advised to wait 15 minutes before leaving our area to be observed for a possible reaction.
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Yes
No
Have you ever had a documented severe allergic reaction (other than hives) to eggs, egg products, or other components of the flu vaccine?
If yes, consult with your physician
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Yes
No
Have you ever had a history of Guillain-Barré (GBS) within 6 weeks of receiving the influenza vaccine?
If yes, consult with your physician
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Yes
No
Do you have any of the following: a moderate or severe illness with or without fever, a bleeding disorder, a serious reaction to a previous flu shot, taking anticoagulants, or a latex allergy?
If yes, consult with your physician
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Yes
No
Race
(Check all that apply)
White
Black
Hispanic or Latino
Asian or Pacific Islander
Other
White
Black
Hispanic or Latino
Asian or Pacific Islander
Other
Please describe your race:
Personal Health History
(Check box if any below apply to you)
Currently smoke or use nicotine products
High cholesterol
High blood pressure
Kidney disease or circulatory problem
Stroke or transient ischemic attack
Diabetes
Clinical coronary heart disease
Carotid artery disease
Peripheral artery disease
Abdominal aortic aneurysm
Heart attack or heart surgery
Atrial Fibrillation
Currently smoke or use nicotine products
High cholesterol
High blood pressure
Kidney disease or circulatory problem
Stroke or transient ischemic attack
Diabetes
Clinical coronary heart disease
Carotid artery disease
Peripheral artery disease
Abdominal aortic aneurysm
Heart attack or heart surgery
Atrial Fibrillation
You checked that you currently smoke or use nicotine products, are you trying to quit?
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Yes
No
Please indicate what tobacco or nicotine products you use:
Cigarettes
Chewing tobacco
E-cigs/vapes/juuls
Cigarettes
Chewing tobacco
E-cigs/vapes/juuls
Are you on medication for cholesterol?
* must provide value
Yes
No
Are you on medication for blood pressure?
* must provide value
Yes
No
Please list any medications you are currently taking:
Family Health History
Check box if your parents, brothers, or sisters have had:
Diabetes
High cholesterol
High blood pressure
Stroke
Heart Disease (before age 55 in men or 65 in women)
Diabetes
High cholesterol
High blood pressure
Stroke
Heart Disease (before age 55 in men or 65 in women)
View equation
View equation
View equation
View equation
View equation
How many days per week do you get 30 minutes or more of exercise?
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None
Some (1-2 days/week)
Regular (≥3 days/week)
None
Some (1-2 days/week)
Regular (≥3 days/week)
Have you ever been diagnosed with gestational diabetes?
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Yes
No
Are you pregnant?
* must provide value
Yes
No
Are you breast-feeding?
* must provide value
Yes
No
By signing below:
I agree to allow staff of UCHealth Healthy Hearts to draw a sample of my blood to measure cholesterol levels, to measure my blood pressure, height and weight, and waist circumference, and to ask me questions about my health history.
I agree to release UCHealth Healthy Hearts and their employees, officers, directors, successors, and assigns from any liability in any way connected with this screening and its measurements.
I understand that:
A registered nurse, medical assistant, exercise physiologist, registered dietitian, or other health care professional will review my results with me.
The measurements from this screening are considered preliminary and approximate. They do not represent a diagnosis of high cholesterol or blood pressure.
I have the responsibility of contacting my doctor if the results of the cholesterol screening suggest I may have a risk of heart disease based on the guidelines of the National Institutes of Health. It is solely my responsibility, and not that of UCHealth Healthy Hearts, to have any additional follow-up appointments done.
Your results will be entered into EPIC (electronic medical records used by UCHealth, Associates of Family Medicine, etc.) to be viewable by your physician or self in MyHealthConnection. You will receive an email with instructions to review your results.
All data collected and used for research purposes will be used to study trends and no individual data will appear in reports, only aggregate, anonymous, and summary data to respect anonymity of participants.
If you have questions about the screening, please contact us at AdultWellness@UCHealth.org or 970.624.1587.
By signing below:
I have been given an opportunity to read the
CDC Vaccine Information Statement (VIS) (8/6/2021) and have read or had explained to me the information about the influenza (flu) vaccine. I have had a chance to ask questions which were answered to my satisfaction. I understand the benefits and risks of the influenza (flu) vaccine. I hereby release UCHealth and its employees from any claims arising out of taking this vaccine.
NOTE: The information provided is for your Healthy Hearts screening
NOT your PSD Health Risk Assessment/Wellness portal. To complete your Know Your Numbers Assessment, click
Here . Don't forget to sign and submit this form as well!
Signature
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Select Add signature button and sign with either mouse or finger. Make sure to hit save!