Language/Idioma* must provide value
English
Español
Fill out the permission form below for your child to participate in the free cholesterol screening. Child's First Name* must provide value
Child's Last Name* must provide value
Child's Date of Birth* must provide value
M-D-Y
Child's Gender Assigned at Birth* must provide value
Male
Female
School District* must provide value
Academy District 20
Poudre School District
St. Vrain School District
Thompson School District
Weld School District (including RE-1, RE-2, RE-4, RE-5J, Greeley 6, Weld 8)
Other (Including Private Schools)
Academy District 20
Poudre School District
St. Vrain School District
Thompson School District
Weld School District (including RE-1, RE-2, RE-4, RE-5J, Greeley 6, Weld 8)
Other (Including Private Schools)
School* must provide value
Academy Endeavor Elementary Academy International Elementary Air Academy High School Antelope Trails Elementary Aspen Valley High School Aspen Valley Middle School Challenger Middle School Chinook Trail Elementary Discovery Canyon Campus Elementary Discovery Canyon Campus Middle School Discovery Canyon Campus High School Discovery Trail Elementary Douglass Valley Elementary Eagleview Middle School Edith Wolford Elementary Explorer Elementary Foothils Elementary Frontier Elementary High Plains Elementary Journey Elementary Journey Middle School Legacy Peak Elementary Liberty High School Mountain Ridge Middle School Mountain View Elementary Pine Creek High School Pioneer Elementary Prairie Hills Elementary Ranch Creek Elementary Rampart High School Rockrimmon Elementary The da Vinci Academy Timberview Middle School Woodmen- Roberts Elementary Other
School* must provide value
Bacon Bauder Beattie Bennett Bethke Blevins Boltz Cache La Poudre Elementary Cache La Poudre Middle Centennial High School Dunn Eyestone Fort Collins High School Fossil Ridge High School Harris Bilingual Irish Johnson Kinard Kruse Laurel Lesher Liberty Common Elementary School Liberty Common Middle School Liberty Common High School Lincoln Middle School Linton Livermore Lopez McGraw O'Dea Olander Polaris ES Polaris MS Poudre High School Preston Putnam Red Feather Lakes Rice Riffenburgh Rocky Mountain High School Shepardson Stove Prairie Tavelli Timnath Traut Webber Wellington Middle School Werner Zach Other
School* must provide value
Columbine Elementary Longmont HS Niwot HS Rocky Mountain Elementary Timberline Elementary Timberline Middle School Trail Ridge Middle School
School* must provide value
Berthoud Elementary Berthoud High School BF Kitchen Big Thompson Bill Reed Carrie Martin Centennial Conrad Ball Cottonwood Plains Coyote Ridge Ferguson High School Garfield High Plains Elementary School High Plains Middle School Ivy Stockwell Laurene Edmonson Lincoln Loveland Classical School Loveland High School Lucile Erwin Mary Blair Monroe Mountain View High School Namaqua New Vision Elementary School New Vision Middle School Ponderosa Sarah Milner Stansberry Thompson Valley High School Truscott Turner Van Buren Walt Clark Winona Other
School* must provide value
Bella Romero K-8 Benjamin Eaton Elementary Brentwood Middle School Butler Elementary Centennial Elementary Chappelow ES Chappelow MS Dayspring Christian Academy HS Dayspring Christian Academy MS Dos Rios Elementary Eaton Elementary Eaton High School Eaton Middle School Franklin Middle School Franklin High School Fred Tjardes School of Innovation Galeton Elementary Gilcrest Elementary Grandview Elementary Greeley Central High School Greeley West High School Heath Middle School Heiman Elementary Highland Elementary Highland Middle School Highland High School Jackson Elementary Jefferson Junior High School Jefferson High School Knowledge Quest Academy Letford Elementary Madison Elementary Maplewood Elementary Martinez Elementary McAuliffe STEM Academy ES McAullife STEM Academy MS Meeker Elementary Milliken Elementary Monfort Elementary Mountain View Elementary Pete Mirich Northridge High School North Valley Middle School Pioneer Ridge Elementary Platte Valley Elementary School Platte Valley Middle School Platte Valley High School Platteville Elementary Prairie Heights Middle School Range View Elementary Roosevelt High School Scott Elementary Severance Middle School Severance High School Shawsheen Elementary Skyview Elementary Tozer Primary School University Elementary School University Middle School University High School West Ridge Academy ES West Ridge Academy MS Windsor Charter Academy ES Windsor Charter Academy MS Windsor Middle School Windsor High School Winograd ES Winograd MS Other
School* must provide value
Estes Park Elementary Estes Park Middle School Estes Park High School Heritage Christian Resurrection Christian ES Resurrection Christian MS Resurrection Christian HS St. Joseph's Academy of Arts and Knowledge (TR Paul) Other
Student ID (known as lunch #) Used as a unique identifier only. This information will be kept confidential.
Teacher Last Name
Class Period For middle and high school students only. If unsure please ask your child!
All results are entered in EPIC (electronic medical record used by UCHealth, Assoc. of Family Medicine, etc.). Your health care provider will receive your child's results in EPIC and you can view them in MyHealthConnection.
Click here if your health care provider does not use EPIC (Banner, Kaiser, Youth Clinic, etc.) or you are unsure and you'd like them to receive a copy of your child's results.
Click here if your health care provider does not use EPIC (Banner, Kaiser, Youth Clinic, etc.) or you are unsure and you'd like them to receive a copy of your child's results.
Healthcare Provider's Name
Healthcare Provider's Clinic or Address
I would like my son or daughter to take part in the Healthy Hearts Screening. I permit my son or daughter to take part in the Healthy Hearts screening and health surveys. I understand a blood sample will be obtained by finger stick method. I understand that weight/height (BMI) and blood pressure measurements will be obtained. I agree to release UCHealth, the participating school districts and their employees, officers, directors, successors, and assigns from any liability in any way connected with this screening and its measurements. Please note: The results of your son or daughter's Healthy Hearts screening provide you with information about your child's current health and possible future risk for heart disease. Abnormal results, in most cases, DO NOT indicate an emergency. Contact your child's healthcare provider for guidance. Parent/Guardian First Name* must provide value
Parent/Guardian Last Name* must provide value
Relationship to Child Mother
Father
Other
Describe Relationship with Child
Si no envía un correo electrónico (email) no puede recibir una notificatión cuando los resultados de su hijo estén listos.NOTA: Recibirá un correo electrónico después del anális de colesterol de su hijo con instrucciones para ver los resultados en MyHealthConnection Parent/Guardian Email:
If you do not provide an email, you will not receive a notification when your child's results are viewable.NOTE: You will receive an email after your child has been screened with instructions on how to access the results via MyHealthConnection. Phone Number
In signing this consent, I understand the following: That all participation is voluntary and can be withdrawn at any time. That all information provided will be handled confidentially and stored in a secure and private location. That involvement poses minimal risk to participants. That the results will be used to educate my child about living a healthy heart lifestyle and for assessment and awareness purposes. That all data is collected and used by Healthy Hearts for research purposes and to study trends. No individual data will appear in data reports; only aggregate, de-identified, summary data will be reported in order to protect the privacy of the participants. That in collaboration with your school district, and in an effort to study community health trends and further research, Healthy Hearts and your school district may request de-identified student information using the provided student ID. No individual identifying health or academic information will be shared between UCHealth and the school district. That I can contact Healthy Hearts at 970-624-5298 to ask any additional questions. In signing this consent, I understand the following: That all participation is voluntary and can be withdrawn at any time. That all information provided will be handled confidentially and stored in a secure and private location. That involvement poses minimal risk to participants. That the results will be used to educate my child about living a healthy heart lifestyle and for assessment and awareness purposes. That all data is collected and used by Healthy Hearts for research purposes and to study trends. No individual data will appear in data reports; only aggregate, de-identified, summary data will be reported in order to protect the privacy of the participants. That I can contact Healthy Hearts at 970-624-5298 to ask any additional questions. Based on my child's results, Healthy Hearts can contact me for follow-up on abnormal values, to inform me about potential family programs, and/or research opportunities.* must provide value
Yes
No
By signing below I verify: I have discussed this screening with my child and am giving my permission for him or her to participate. Students may decide not to participate in the screening even if parents have given full permission. Parent/Guardian Signature* must provide value
Click Add signature button and sign with mouse or finger. Make sure to hit save!
Family Health Questionnaire Click the Submit button at the bottom of this form to complete the permission for your child. Part 1: Health Habits
2. How many days per week do YOU (parent/guardian) eat breakfast?
3. How many servings per day do YOU (parent/guardian) eat of fruits and vegetables combined, not including juice? (1 serving is 1 cup of raw or 1/2 cup cooked)
Part 2: Health History 1. Does anyone in the student's immediate biological family (mother, father, brother, sister) have:
Yes
No
Do not know
b. High cholesterol?
Yes
No
Do not know
c. Overweight/obesity?
Yes
No
Do not know
d. Diabetes?
Yes
No
Do not know
e. Depression, anxiety, or mental illness?
Yes
No
Do not know
f. Asthma?
Yes
No
Do not know
g. Stroke?
Yes
No
Do not know
h. Heart Disease or Heart Attack (before age 55 in men or 65 in women)?
Yes
No
Do not know
2. Does your child have asthma?
Yes No
3. Does your child have diabetes?
Yes No
Part 3: Lifestyle 1. How many days per week do YOU (parent/guardian) get at least 30 minutes of exercise?
2. Does anyone in the family smoke?
Yes No
3. Does anyone in the family use electronic cigarettes/vape pens such as Juuls, Suorin drop, etc.?
Yes No
If yes, do you smoke or vape in the home or in the car?
Yes No
4. How many hours of sleep do YOU (parent/guardian) average per night?
5. How would you describe your stress/anxiety level over the past few weeks?
No stress
Low stress
Average stress
High stress
Very high stress
No stress
Low stress
Average stress
High stress
Very high stress
Part 4: Demographic Information 1. What is the race/ethnicity of your child?Check all that apply
White
Hispanic or Latino
Black
Asian or Pacific Islander
Other
White
Hispanic or Latino
Black
Asian or Pacific Islander
Other
Please describe student's race/ethnicity.
2. What is your (parent/guardian) age bracket?
< 25 years
25-30 years
31-40 years
41-50 years
51-60 years
>60 years
< 25 years
25-30 years
31-40 years
41-50 years
51-60 years
>60 years
3. Does your family participate in the free and reduced lunch program at your school?
Yes
No
4. What is your (parent/guardian) highest education level?
Some high school
High school degree
Some college
Technical or trade school
College degree
Some post grad work
Post grad degree
Some high school
High school degree
Some college
Technical or trade school
College degree
Some post grad work
Post grad degree
5. What is your (parent/guardian) marital status?
Married
Divorced
Single
Other
Prefer not to say
Married
Divorced
Single
Other
Prefer not to say
Describe:
Reminder: You will receive a confirmation email and a notification email indicating your child's screening has been completed. Please verify your email address before clicking Submit. ______ If incorrect, please scroll up to make any changes you need in the parent/guardian email field. ______ ______ . Haga el permiso abajo para que su hijo participe en el análisis del colesterol. Nombre del hijo* must provide value
Apellido del hijo* must provide value
Fecha de nacimiento del hijo* must provide value
M-D-Y
El género del hijo* must provide value
Masculino
Femenino
Distrito Escolar* must provide value
Academy District 20
Poudre School District
St. Vrain School District
Thompson School District
Weld School District (including RE-2, RE-4, RE-5J, Greeley 6)
Otro
Academy District 20
Poudre School District
St. Vrain School District
Thompson School District
Weld School District (including RE-2, RE-4, RE-5J, Greeley 6)
Otro
Escuela Academy Endeavour Elementary Academy International Elementary Air Academy High School Antelope Trails Elementary Aspen Valley High School Aspen Valley Middle School Challenger Middle School Chinook Trail Elementary Discovery Canyon Campus Elementary Discovery Canyon Campus Middle School Discovery Canyon Campus High School Discovery Trail Elementary Douglass Valley Elementary Eagleview Middle School Edith Wolford Elementary Explorer Elementary Foothils Elementary Frontier Elementary High Plains Elementary Journey K8 Elementary Journey K8 Middle School Legacy Peak Elementary Liberty High School Mountain Ridge Middle School Mountain View Elementary Pine Creek High School Poineer Elementary Prairie Hills Elementary Ranch Creek Elementary Rampart High School Rockrimmon Elementary Schools in the Woods The da Vinci Academy Timberview Middle School Woodmen- Roberts Elementary Other
Escuela* must provide value
Bacon Bauder Beattie Bennett Bethke Blevins Boltz Cache La Poudre Elementary Cache La Poudre Middle Centennial High School Dunn Eyestone Fort Collins High School Fossil Ridge High School Harris Bilingual Irish Johnson Kinard Kruse Laurel Lesher Liberty Common Elementary School Liberty Common High School Lincoln Middle School Linton Livermore Lopez McGraw O'Dea Olander Polaris Poudre High School Preston Putnam Red Feather Lakes Rice Riffenburgh Rocky Mountain High School Shepardson Stove Prairie Tavelli Timnath Traut Webber Wellington Middle School Werner Zach Other
Escuela* must provide value
Columbine Elementary Longmont HS
Escuela* must provide value
Berthoud Elementary Berthoud High School BF Kitchen Big Thompson Bill Reed Carrie Martin Centennial Conrad Ball Cottonwood Plains Coyote Ridge Ferguson High School Garfield High Plains Ivy Stockwell Laurene Edmonson Lincoln Loveland Classical School Loveland High School Lucile Erwin Mary Blair Monroe Mountain View High School Namaqua New Vision Charter School Ponderosa Sarah Milner Stansberry Thompson Valley High School Truscott Turner Van Buren Walt Clark Winona Other
Escuela* must provide value
Bella Romero K-8 Benjamin Eaton Elementary Brentwood Middle School Butler Elementary Centennial Elementary Chappelow ES Chappelow MS Dos Rios Elementary Eaton Elementary Eaton High School Eaton Middle School Franklin Middle School Franklin High School Fred Tjardes School of Innovation Galeton Elementary Gilcrest Elementary Grandview Elementary Greeley Central High School Greeley West High School Heath Middle School Heiman Elementary Highland Elementary Highland Middle School Highland High School Jackson Elementary Jefferson Junior High School Jefferson High School Knowledge Quest Academy Letford Elementary Madison Elementary Maplewood Elementary Martinez Elementary McAuliffe STEM Academy ES McAullife STEM Academy MS Meeker Elementary Milliken Elementary Monfort Elementary Mountain View Elementary Pete Mirich Northridge High School North Valley Middle School Pioneer Ridge Elementary Platte Valley Elementary School Platte Valley Middle School Platte Valley High School Prairie Heights Middle School Range View Elementary Roosevelt High School Scott Elementary Severance Middle School Severance High School Shawsheen Elementary Skyview Elementary Tozer Primary School University Elementary School University Middle School University High School West Ridge Academy ES West Ridge Academy MS Windsor Charter Academy ES Windsor Charter Academy MS Windsor Middle School Windsor High School Winograd ES Winograd MS Other
Escuela* must provide value
Academy of the Arts and Knowledge Estes Park Elementary Heritage Christian Resurrection Christian St. Joseph's Timberline Elementary Other
El número de identificación (número de almuerzo) Usado como un identificador único solamente. Esta información se mantendrá confidencial.
Apellido de maestro/a
Período de clase Solo para estudiantes de secundaria. Si no está seguro, pregúntele a su hijo.
Todos los resultados son ingresados en EPIC (expediente médico electrónico usado por UCHealth, Assoc. of Family Medicine etc.). Los resultados de su hijo se ingresarán en EPIC para ser visibles por su doctor y usted a través de MyHealth Connection.
Haga clic aquí si su proveedor de atención médica no utiliza EPIC (Banner, Kaiser, Youth Clinic, etc.) o si no está seguro y le gustaría recibir una copia de los resultados de su hijo.
Haga clic aquí si su proveedor de atención médica no utiliza EPIC (Banner, Kaiser, Youth Clinic, etc.) o si no está seguro y le gustaría recibir una copia de los resultados de su hijo.
El nombre del doctor
El nombre de la clínica o correo
Quiero que mi hijo(a) participe en el análisis de Healthy Hearts. Yo permito a mi hijo(a) a participar en el análisis de Healthy Hearts y en encuestas de salud. Entiendo que se obtendrá una muestra de sangre por medio de un piquete en el dedo. Entiendo que se obtendrá presión sanguínea y altura y peso (BMI). Estoy de acuerdo de no responsabilizar a la University of Colorado Health, o los distritos escolares participantes así como a sus empleados, oficiales, directores, sucesores, y cesionarios de cualquier manera con este análisis y sus resultados. (Por favor tome nota: Los resultados del análisis proveen información sobre la salud actual de su hijo/a y si tiene la posibilidad de riesgo en el futuro de una enfermedad cardiaca. Los resultados anormales, en la mayoría de los casos, NO significan que es una emergencia. Póngase en contacto con el doctor de su hijo para más información y para que se guíe con los resultados.) El primer nombre de padre/madre/tutor* must provide value
El apellido de padre/madre/tutor* must provide value
El apellido de padre/madre/tutor Madre
Padre
Otro
Relación al hijo
Número de teléfono
Al firmar este consentimiento, usted entiende lo siguiente: Que toda participación es voluntaria y puede ser retirada en cualquier momento. Que toda información proporcionada será confidencial y se almacena en un lugar seguro y privado. Que la participación supone un riesgo mínimo a los participantes. Que los resultados se utilizarán: para educar a su hijo/a sobre un estilo de vida saludable para el corazón; para evaluación y conocimiento; y para propósitos de investigación. De todos los datos recogidos y utilizados de Healthy Hearts para investigación, serán utilizados para estudiar las tendencias. No aparecerán los datos individuales en los informes, sólo el conjunto de los datos anónimos, y el resumen de datos para respetar el anonimato de los participantes. En colaboración con su distrito escolar y para estudiar las tendencias de salud y para investigación, Healthy Hearts y su distrito escolar puede pedir por información anónima de su estudiante con su número de identificación de estudiante. No comparten los datos individuales de salud o de académica entre UCHealth o distrito escolar. Que usted puede ponerse en contacto con Healthy Hearts al 970-624-5298 para hacer preguntas adicionales. Al firmar este consentimiento, usted entiende lo siguiente: Que toda participación es voluntaria y puede ser retirada en cualquier momento. Que toda información proporcionada será confidencial y se almacena en un lugar seguro y privado. Que la participación supone un riesgo mínimo a los participantes. Que los resultados se utilizarán: para educar a su hijo/a sobre un estilo de vida saludable para el corazón; para evaluación y conocimiento; y para propósitos de investigación. De todos los datos recogidos y utilizados de Healthy Hearts para investigación, serán utilizados para estudiar las tendencias. No aparecerán los datos individuales en los informes, sólo el conjunto de los datos anónimos, y el resumen de datos para respetar el anonimato de los participantes. Que usted puede ponerse en contacto con Healthy Hearts al 970-624-5298 para hacer preguntas adicionales. Basado en los resultados de mi hijo(a), Healthy Hearts puede contactarme para dar seguimiento sobre resultados de riesgo alto, programas potenciales de familia, y para oportunidades de investigaciones. * must provide value
Sí
No
Al firmar abajo verifico que: Hablé con mi hijo/a sobre esta evaluación de salud y análisis de colesterol y doy mi permiso para participar (Nota: aunque los padres den su permiso, al final el estudiante también tiene que dar su permiso para hacer el análisis). Firma de padre/madre/tutor* must provide value
Haga clic en el botón para agregar su firma y firme con el ratón o su dedo. ¡Asegúrese de guardar el firme!
Encuesta de salud familiar Asegúrate de presionar submit (enviar) debajo de esta cédula para entregar el permiso de su hijo. HABITOS SALUDABLES DE LOS PADRES
2. ¿Cuántas días por semana come usted el desayuno?
3. ¿Cuántas porciones por día come usted de frutas y verduras (combinadas)? (1 porción es 1 taza de frutas/verduras frescas o media taza de verduras cocidas)?
HISTORIA FAMILIAR 1. ¿Alguien en la familia biológica inmediata (madre, padre, hermanos, hermanas) tiene:
Sí
No
No lo sé
b. Colesterol alto?
Sí
No
No lo sé
c. Sobrepeso/obeso?
Sí
No
No lo sé
d. Diabetes?
Sí
No
No lo sé
e. Depresión, ansiedad, o una enfermedad o trastorno mental?
Sí
No
No lo sé
f. Asma?
Sí
No
No lo sé
g. Accidente cerebral?
Sí
No
No lo sé
h. Ataque cardiaco o enfermedades cardiacas (antes de los 55 años en hombres o 65 en mujeres)?
Sí
No
No lo sé
2. ¿Su hijo tiene asma?
Sí No
3. ¿Su hijo tiene diabetes?
Sí No
ESTILO DE VIDA 1. ¿Cuántos días hace usted 30 minutos o más de ejercicio?
2. ¿Existen fumadores en su familia?
Sí No
3. ¿Existe alguien en la familia que usa cigarrillos electrónicos/plumas de vape/Juul?
Sí No
En caso afirmativo, ¿fuma o usa una pluma de vape en la casa o en el carro?
Sí No
4. ¿Por cuántas horas duerme usted cada noche?
5. ¿Cómo calificaría su nivel de estrés durante las últimas semanas?
No Estrés
Un poco
Normal
Bastante
Muchísimo Estrés
No Estrés
Un poco
Normal
Bastante
Muchísimo Estrés
Información demográfica 1. ¿Cuál es el origen étnico del hijo? Marque todas las que apliquen
Blanco (no hispano)
Hispano or Latino
Negro (no hispano)
Asiático o de la islas del Pacifico
Otro
Blanco (no hispano)
Hispano or Latino
Negro (no hispano)
Asiático o de la islas del Pacifico
Otro
Describa el origen étnico del hijo por favor
2. ¿Cuál es su grupo de edad (padre/guardián)?
< 25 años
25-30 años
31-40 años
41-50 años
51-60 años
>60 años
< 25 años
25-30 años
31-40 años
41-50 años
51-60 años
>60 años
3. ¿Participa su familia en el programa de descuentos en el almuerzo?
Sí
No
4. El nivel de educación más alto que Ud. ha logrado:
Menos que la preparatoria completa
Certificado de la preparatoria
Algunos estudios de la universidad
Escuela técnica
Título de universidad
Algunos estudios de postgrado
Título de postgrado
Menos que la preparatoria completa
Certificado de la preparatoria
Algunos estudios de la universidad
Escuela técnica
Título de universidad
Algunos estudios de postgrado
Título de postgrado
5. ¿Cuál es su estado civil?
Casado
Divorciado
Soltero
Otro
Prefiero no decirlo
Casado
Divorciado
Soltero
Otro
Prefiero no decirlo
Describa:
Recordatorio: Usted recibirá un correo electrónico cuando el análisis de colesterol de su hijo esta termindao. Verifique que su correo electrónico es correcto antes de presionar "submit" (enviar) por favor. Si es incorrecto, desplácese hacia arriba y realice los cambios necesarios en la sección de correo electrónico. ______ ______ .
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