2017 YSIT STUDENT HEALTH SURVEY
Name: 


A red asterisk (*) indicates required questions.

  1. Do you have asthmas? (If no, skip questions 2-3)*
    Yes
    No


  1. Do you use an inhaler?
    Yes
    No


  1. Level of severity- asthma 


  1. Do you have a history of epileptic seizures? (If no, skip question 5)
    *
    Yes
    No


  1. How often do you have these seizures?


  1. Do you have any other long-term health conditions? (If no, skip question 7)*
    Yes
    No


  1. Indicate these other long-term health conditions?


  1. Specify other conditions:

    List only conditions that we should be aware of in case of emergency.*


  1. Do you take any medications? (If no, skip question 10)*
    Yes
    No


  1. Specify medications:

    List only medications that we should be aware of in case of an emergency.


  1. Are you allergic to any medications?*
    Yes
    No





Chris Fasone