St. Joseph Jr-Sr High School    Hilo, Hawaii Health Questionnaire Print 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 and Frequency_______________________________________________________________


Student's Doctor___________________________________________________________________


Comments___________________________________________________________________________

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______________________________________________________


Signature of parent/guardian__________________________________Date_________________


Home phone_______________________________ Work phone_______________________________