San Antonio Are Council of Girl Scouts
Health History Record
This health history is to be completed and signed by parent/guardians of girls or by adult members themselves		 San Antonio Area Council
of Girl Scouts, Inc
P.O. Box 790339
San Antonio, TX 78279
Name: Desmond Odie Howling aka "SKIP" Date of Adoption: Jan 23, 1998
Address: 111 My Street Live Oak, TX 78233 Troop #: 513
Mascot Mom: Janice Lapham Phone: 000-555-8877
Home Address: SAME AS ABOVE
In Emergency Notify: Beverly Kay Relationship: Troop 1st Aider
Address: 111 Her Street Schertz, TX 78154 Phone: 000-555-7788
Family Physician: Dr Doolittle Phone: 000 555-7444
Insurance carrier: 1-800-555-2471
Live Oak Animal Hospital 		Policy or Group # Acct 2517207
ID # 12345-01
Name of Dentist/Orthodontist: Canine Dental Phone: 000 555-1234
Special Instructions: Skip likes root vegetables, like potatoes. Please do not let him over eat on French fries, they're his favorite.
Part I: Illness and injuries (check those that apply and give appropriate dates)

 Ear Infection
Bleeding/Clotting
Hytertension X None Applicable

 Heart Defect/Disease
Seizure
Diabetes
Other:
Our Mascot Host has troop permission to use the following over the counter medications:
X Aspirin
X Neosporin
X Non Aspirin Substitute
X Pepto-Bismol
Any Leader and troop 1st aider deems necessary.
Date of last health examination Jan 1998
Were any complicating medical problems noted in last health examination?
Since last health exam has mascot had:
Is mascot currently under the care of a vet? Always
a serious injury requiring medical attention NO
an illness lasting more then five days NO
any prescription or over-the-counter medications NO
a surgical operation or fracture NO
Treatment in a hospital or emergency room NO
any exposure to a contagious disease NO
Other non-prescription over the counter Remedies Control for Dogs (Fleas)
Please explain any "yes" answers to the above questions. Include dates:

Part II: Allergies Part IV: Immunization History

 Animals
Hay fever Immunization: Date:

 Pollen
Food Distemper 9-98

 Medicines
Insect stings Hepatitis 9-98

 Plants
Other Teptospirosis 9-98
Part III: Other Behaviors Bordetella

9-98


 None applicable Parainfluenza 9-98
X House Broken Parvo 9-98

 Motion sickness
Biting Corona 9-98
X Chasing Cars or Cats Rabies 9-98
X Begging at Table Worming 9-98
Other (specify)
Please explain any items that are checked. Indicate any information useful to the adult in charge in relation to any health conditions.

Also, indicate any activities to be encouraged or restricted.

I know of no reason(s), other than the information indicated on this form, why Our Mascot should not participate in prescribed activities except as noted.
Signature of Mascot Mom Janice Lapham Date 26 May 1998