The code block below illustrates how one might use # and // as comments in your logic and calculations.

# Text can be put here to explain what the logic/calculation does and why.
if ([field1] = '1' and [field2] > 7,

	// This comment can explain what the next line does.
	[score] * [factor],

	// Return '0' if the condition is False.
	0
)

Working …

This value you provided is not a number. Please try again.

This value you provided is not an integer. Please try again.

The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to 9-digit number, excluding leading zeros). Please try again.

The value you provided must be within the suggested range

The value you provided is outside the suggested range

This value is admissible, but you may wish to double check it.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit North American phone number (like 415 555 1212). Please re-enter it now.

This field must be a valid email address (like joe@user.com). Please re-enter it now.

The value you provided could not be validated because it does not follow the expected format. Please try again.

Required format:

Permission for Screening

Thank for your interest in screening with Healthy Hearts and Minds.

Please complete the survey below before attending the screening.

Thank you!

Preferred Language/Idioma preferido

English

Español

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Permission for Screening

What company/event are you screening for?

* must provide value

Evre

Flood and Peterson

In-Situ

Platte Valley School District

Poudre School District

Thompson School District

Sonnenalp

Waterpik

Weld School District

Other (ex. Community Event/Health Fair/Worksite Wellness)

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First Name

* must provide value

Last Name

* must provide value

Click here if you prefer another name

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Your Preferred Name

Location of Screening

* must provide value

Location

Location of Screening

Date of Birth

* must provide value

M-D-Y

Sex Assigned at Birth

* must provide value

Male

Female

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Click here if you identify with a sex different than the one assigned at birth.

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Describe or comment:

Home Address (Street)

City

State

ZIP Code

Phone Number

Email
Note: You will receive a notification email when your screening has been completed.

* must provide value

Your results will be entered into EPIC (electronic medical records used by UCHealth, Associates in Family Medicine, etc.) to be viewable by your physician or self in MyHealthConnection.

Check if you are:

* must provide value

Benefited employee

Benefited family member

Neither (not on PSD insurance, will self-pay)

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Insurance ID #

* must provide value

Employee ID #

* must provide value

Are you participating in the onsite flu-shot clinic?

* must provide value

Yes

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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.

* must provide value

Yes

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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

* must provide value

Yes

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Have you ever had a history of Guillain-Barré (GBS) within 6 weeks of receiving the influenza vaccine?
If yes, consult with your physician

* must provide value

Yes

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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

* must provide value

Yes

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Race/Ethnicity
(Check all that apply)

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

You checked that you currently smoke or use nicotine products, are you trying to quit?

* must provide value

Yes

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Please indicate what tobacco or nicotine products you use:

Cigarettes

Chewing tobacco

E-cigs/vapes/juuls

Are you on medication for cholesterol?

* must provide value

Yes

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Are you on medication for blood pressure?

* must provide value

Yes

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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)

How many days per week do you get 30 minutes or more of exercise?

* must provide value

None

Some (1-2 days/week)

Regular (≥3 days/week)

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Have you ever been diagnosed with gestational diabetes?

* must provide value

Yes

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Are you pregnant?

* must provide value

Yes

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Are you breast-feeding?

* must provide value

Yes

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By signing below:

I agree to allow staff of UCHealth Healthy Hearts and Minds 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 Minds 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 and Minds, 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.

Benefitted PSD employees and dependents may receive a follow up email or phone call from the Simplified Benefits Administrators Lifestyle Health Program team to determine interest in enrolling in their free program. You have access to exercise classes, nutrition consults and nurse consults at no cost. Click here for more information.

I do not wish for the Lifestyle Health Program to contact me.

diabetes

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high chol

View equation

high bp

View equation

stroke

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heartdisease

View equation

Signature

* must provide value

Add signature

NOTE: The information provided is for your Healthy Hearts and Minds 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!

To sign up for your appointment, click submit below to find a time that works for you.

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.