School District
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Academy 20 School District
Colorado Springs District 11
District 49
Harrison
Poudre School District
St. Vrain Valley School District
Steamboat Springs School District
Thompson School District
Weld School Districts
Widefield School District
Other
Academy 20 School District
Colorado Springs District 11
District 49
Harrison
Poudre School District
St. Vrain Valley School District
Steamboat Springs School District
Thompson School District
Weld School Districts
Widefield School District
Other
School
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Academy Endeavor Elementary Academy International Elementary Antelope Trails Elementary Chinook Trail Elementary Discovery Canyon Campus Elementary Discovery Trail Elementary Douglass Valley Elementary Edith Wolford Elementary Explorer Elementary Foothils Elementary Frontier Elementary High Plains Elementary Journey Elementary Legacy Peak Elementary Mountain View Elementary Pioneer Elementary Prairie Hills Elementary Ranch Creek Elementary Rockrimmon Elementary Woodmen- Roberts Elementary Other
School
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Banning Lewis Ranch Academy Elementary Bennett Ranch ES Evans ES Falcon Elementary School of Technology Grand Peak Academy Elementary Inspiration View ES James Irwin ES-Canada Drive Liberty Tree Academy Elementary Meridian Ranch ES Mountain View Academy Elementary Odyssey ES Pioneer Technology & Arts Academy Elementary Remington ES Ridgeview ES Rocky Mountain Classical Academy Elementary Springs Ranch ES Springs Studio For Academic Excellence Elementary Stetson ES Woodmen Hills ES Other
School
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Adams Elementary Audubon Elementary Bristol Elementary Buena Vista Elementary Carver Elementary Chipeta Elementary Christa Mcauliffe Elementary Columbia Elementary Edison Elementary Freedom Elementary Fremont Elementary Grant Elementary Henry Elementary Howbert Elementary Jackson Elementary Keller Elementary King Elementary Madison Elementary Martinez Elementary Midland Intl. Elementary Monroe Elementary Penrose Elementary Queen Palmer Elementary Rogers Elementary Rudy Elementary Scott Elementary Spark Online Academy Combined Steele Elementary Stratton Elementary Taylor Elementary Trailblazer Elementary Twain Elementary West Elementary Wilson Elementary D11 Other
School
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North Routt Community Charter Elementary Sleeping Giant Elementary Soda Creek Elementary Strawberry Park Elementary Other
School
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Atlas Preparatory Elementary Bricker Elementary Centennial Elementary Giberson Elementary James Irwin Elementary Monterey Elementary Oak Creek Elementary Otero Elementary Pikes Peak Elementary Soaring Eagles Elementary Stratmoor Hills Elementary Stratton Meadows Elementary The Vanguard School Elementary Turman Elementary Wildflower Elementary Other
School
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French Elementary Grand Mountain Elementary Haven Elementary James Madison Elementary King Elementary Pinello Elementary Sunrise Elementary Talbott Steam Innovation Elementary Venetucci Elementary Webster Elementary Widefield Elementary Other
School
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Bacon Bamford Bauder Beattie Bennett Bethke Cache La Poudre Elementary Dunn Eyestone Harris Bilingual Irish Johnson Kruse Laurel Liberty Common Elementary Linton Livermore Lopez McGraw O'Dea Olander Polaris Elementary PSD Global Academy Putnam Red Feather Lakes Rice Riffenburgh Shepardson Stove Prairie Tavelli Timnath Traut Werner Zach Other
School
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Alpine Black Rock Blue Mountain Burlington Centennial Central Columbine Eagle Crest Erie Elementary Fall River Grandview Hygiene Indian Peaks Legacy Longmont Estates Lyons Elementary Mead Mountain View Niwot Northridge Prairie Ridge Red Hawk Rocky Mountain Sanborn Soaring Heights Elementary Thunder Valley Elementary Timberline Elementary Other
School
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Berthoud Elementary BF Kitchen Big Thompson Carrie Martin Centennial Cottonwood Plains Coyote Ridge Garfield High Plains Elementary Ivy Stockwell Laurene Edmonson Lincoln Loveland Classical School Namaqua New Vision Elementary Peakview Academy Ponderosa Riverview Elementary Sarah Milner Stansberry Truscott Van Buren Winona Other
School
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Bella Romero K-8 Benjamin Eaton Butler Centennial Chappelow Elementary D6 Online Academy Elementary Dos Rios Eaton Elementary Elwell Galeton Gilcrest Grandview Heiman Highland Elementary Hollister Lake Jackson Knowledge Quest Academy Madison Maplewood Martinez McAuliffe Elementary STEM Academy Meeker Milliken Monfort Mountain View Elementary Orchard Hill Pete Mirich Pioneer Ridge Platte Valley Elementary Platteville Range View Scott Fred Tjares School of Innovation Shawsheen Skyview Tozer Primary School University Elementary West Ridge Academy Elementary Windsor Charter Academy Elementary Winograd Other
School
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Academy of the Arts Dayspring Christian Academy ES Estes Park Elementary Heritage Christian Resurrection Christian Elementary St. Josephs Other
School
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First Name:
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Last Name:
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Last Name Initial:
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Today M-D-Y
Teacher's Last Name:
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1. About how many times does your heart beat in one day?
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12,000
4,000
100,000
I don't know
12,000
4,000
100,000
I don't know
2. Your heart is made of _____________.
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Bone
Muscle
Tendon
I don't know
Bone
Muscle
Tendon
I don't know
3. The heart is part of the ______________ system.
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Digestive
Immune
Cardiovascular
I don't know
Digestive
Immune
Cardiovascular
I don't know
4. What puts oxygen into your blood?
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Stomach
Lungs
Kidneys
I don't know
Stomach
Lungs
Kidneys
I don't know
5. Your heart is the size of _______________.
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Your fist
A football
An egg
I don't know
Your fist
A football
An egg
I don't know
6. HDL (the healthy cholesterol) removes _______________ from the blood.
* must provide value
LDL (the lousy cholesterol)
Oxygen
Red blood cells
I don't know
LDL (the lousy cholesterol)
Oxygen
Red blood cells
I don't know
7. Eating healthy foods like fish, avocado, nuts/seeds, and olive oil can raise your HDL cholesterol.
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True
False
I don't know
8. Try to eat ___ servings of fruits and vegetables every day for a healthy heart and mind.
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2
3
5
I don't know
9. What is the Serving Size of this snack?
3 cookies
6 cookies
1 cookie
I don't know
3 cookies
6 cookies
1 cookie
I don't know
10. Vaping can damage your blood vessels.
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True
False
I don't know
11. Try to exercise for ___ minutes every day for a healthy heart and mind.
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15 minutes
60 minutes
30 minutes
I don't know
15 minutes
60 minutes
30 minutes
I don't know
12. Stress can lead to high blood pressure and heart disease.
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True
False
I don't know
Gender
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Boy
Girl
Prefer to self-describe
Prefer not to say
Boy
Girl
Prefer to self-describe
Prefer not to say
Gender
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Boy
Girl
Prefer not to say
Birthday
Month
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Prefer not to say January February March April May June July August September October November December
Prefer not to say 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
2012 2013 2014 2015 2016 Prefer not to say
1. Drink sugar-sweetened beverages?
(only count drinks with added sugar like soda, lemonade, iced tea, energy drinks or juice with added sugar)
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0 1 2 3 4 5 6 7 Prefer not to say
days per week
2. Eat 5 servings of fruits and vegetables combined ?
(1 serving is 1/2 cup; it could easily fit in your hand)
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0 1 2 3 4 5 6 7 Prefer not to say
days per week
3. Exercise for a total of 60 minutes by the end of the day?
(either all at once or broken up)
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0 1 2 3 4 5 6 7 Prefer not to say
days per week
4. Get exposed to secondhand smoke or vape ?
(near or next to someone who is smoking or vaping)
* must provide value
0 1 2 3 4 5 6 7 Prefer not to say
days per week
5. Will you increase the amount of fruits and vegetables you eat every day?
Yes, by 1 serving
Yes, by 2 servings
Yes, by 3+ servings
No, I am not going to change
No, I already get the recommended amount
Prefer not to say
Yes, by 1 serving
Yes, by 2 servings
Yes, by 3+ servings
No, I am not going to change
No, I already get the recommended amount
Prefer not to say
6. Will you increase the amount you exercise each day?
Yes, by 10 minutes
Yes, by 20 minutes
Yes, by 30+ minutes
No, I am not going to change
No, I already get the recommended amount
Prefer not to say
Yes, by 10 minutes
Yes, by 20 minutes
Yes, by 30+ minutes
No, I am not going to change
No, I already get the recommended amount
Prefer not to say
7. Will you cut back the amount of sugary drinks you drink per day?
Yes, by 1 drink
Yes, by 2 drinks
Yes, by 3+ drinks
No, I am not going to change
No, I do not drink sugary drinks
Prefer not to say
Yes, by 1 drink
Yes, by 2 drinks
Yes, by 3+ drinks
No, I am not going to change
No, I do not drink sugary drinks
Prefer not to say
8. Will you read food labels more often?
Yes
No
No, I already read food labels
Prefer not to say
Yes
No
No, I already read food labels
Prefer not to say
9. Will you smoke/chew tobacco?
I will not smoke/chew tobacco
I will smoke/chew tobacco
I'm unsure at this time
Prefer not to say
I will not smoke/chew tobacco
I will smoke/chew tobacco
I'm unsure at this time
Prefer not to say
I will not vape
I will vape
I'm unsure at this time
Prefer not to say
I will not vape
I will vape
I'm unsure at this time
Prefer not to say
Please share something you learned, a health goal you have set, feedback, or any other questions you would like answered by the Healthy Hearts and Minds staff! Leave blank if this doesn't apply.