St. Joseph Jr-Sr High School    Hilo, Hawaii Health Questionnaire Online Version

Student Name   Grade    Birthdate  Allergies Please list any medical condition your child might have (asthma, epilepsy, diabetes, migraines, ADD/ADHD, etc.). Condition(s) Year diagnosed    Medications   Dosage/Frequency Student's Doctor Please list any significant injury or illness your child has had in the last few years (head injury, broken bones, bad sprains, surgeries, etc.). Injury/Illness   Month/Year  Comments Parent/Guardian   Date  Home Phone   Work Phone  Email

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