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
)

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Required format:

Healthy Hearts and Minds Permission Form

Promoting heart health education and cardiovascular research in Colorado.

Your student has an opportunity to participate in a heart health screening. The American Academy of Pediatrics recommends that all children, regardless of family history and lifestyle choices, have their cholesterol checked between the ages of 9 and 11 years and again as a teen. It's important, it's easy and it's free!

Please complete the form below.

Make sure to sign before submitting!

Language/Idioma

* must provide value

English

Español

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School District

* must provide value

Academy District 20

Fountain-Fort Carson School District 8

Harrison School District 2

Lewis Palmer School District 38

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)

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School

* must provide value

School

* must provide value

School

* must provide value

School

* must provide value

School

* must provide value

School

* must provide value

School

* must provide value

School

* must provide value

School

* must provide value

Fill out the permission form below for your student to participate in the free cholesterol screening.

Student's First Name

* must provide value

Student's Last Name

* must provide value

Click here if your student has a preferred name

Student's Preferred Name

Student's Date of Birth

* must provide value

M-D-Y

Student's Sex Assigned at Birth

* must provide value

Male

Female

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Click here if your student identifies with a sex different than the one assigned at birth.

Describe:

Student ID (known as lunch #)

Teacher Last Name

Class Period

All results are entered in EPIC (electronic medical record used by UCHealth, Associates in Family Medicine, Fort Collins Youth Clinic, etc.). Your health care provider will receive your student's results in EPIC and you can view them in MyHealthConnection.

Click here if your health care provider does not use EPIC (Banner, Kaiser, Loveland Youth Clinic, etc.) or you are unsure and you'd like them to receive a copy of your student's results.

Healthcare Provider's Name

Healthcare Provider's Clinic or Address

I would like my student to take part in the Healthy Hearts and Minds Screening.

I permit my student to take part in the Healthy Hearts and Minds 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 student's Healthy Hearts and Minds screening provide you with information about your student's current health and possible future risk for heart disease. Abnormal results, in most cases, DO NOT indicate an emergency. Contact your student's healthcare provider for guidance.

Parent/Guardian First Name

* must provide value

Parent/Guardian Last Name

* must provide value

Relationship to Student

Mother

Father

Other

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Describe Relationship with Student

Parent/Guardian Email:

If you do not provide an email, you will not receive a notification when your student'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 student about living a healthy heart lifestyle and for assessment and awareness purposes.

That all data is collected and used by Healthy Hearts and Minds 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 and Minds at 970-624-5298 to ask any additional questions.

Based on my student's results, Healthy Hearts and Minds can contact me for follow-up on abnormal values, to inform me about potential family programs, and/or research opportunities.

* must provide value

Yes

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By signing below I verify:
I have discussed this screening with my student and am giving my permission for them to participate. Students may decide not to participate in the screening even if parents have given full permission.

Parent/Guardian Signature

* must provide value

Add signature

Family Health Questionnaire
Your responses help improve local community programs and resources. All data is aggregated and de-identified. Personal name and information will not be shared. Please fill out these optional questions from your (parent/guardian) perspective.

Click the Submit button at the bottom of this form to complete the permission for your student.

Part 1: Health Habits

1. How many times per week do YOU (parent/guardian) drink a sugar-sweetened drink (12 ounces)? (examples: soda, juice with added sugar, lemonade, coffee/tea with added sugar)

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:

a. High blood pressure?

Yes

Do not know

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b. High cholesterol?

Yes

Do not know

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c. Overweight/obesity?

Yes

Do not know

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d. Diabetes?

Yes

Do not know

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e. Depression, anxiety, or mental illness?

Yes

Do not know

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f. Asthma?

Yes

Do not know

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g. Stroke?

Yes

Do not know

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h. Heart Disease or Heart Attack (before age 55 in men or 65 in women)?

Yes

Do not know

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2. Does your student have asthma?

Yes

Do not know

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3. Does your student have diabetes?

Yes

Do not know

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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

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3. Does anyone in the family use electronic cigarettes/vape pens such as Juuls, Suorin drop, etc.?

Yes

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If yes, do you smoke or vape in the home or in the car?

Yes

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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

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Part 4: Demographic Information

1. What is the race/ethnicity of your student?
Check all that apply

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

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3. Does your family participate in the free and reduced lunch program at your school?

Yes

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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

5. What is your (parent/guardian) marital status?

Married

Divorced

Single

Other

Prefer not to say

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Describe:

Reminder: You will receive a confirmation email and a notification email indicating your student's screening has been completed. Please verify your email address before clicking Submit.

Email: ______
If incorrect, please scroll up to make any changes you need in the parent/guardian email field.

You will receive an email sent to address entered above confirming we have received your permission for ______ ______.

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.