VIRGINIA PADUA MATTSON, D.M.D. Patient Health History 11717 Bernardo Plaza Ct, Suite 100, San Diego, CA 92128 www.vpmattsondmd.com   Telephone: 858.673.1633

Today's Date

First Name Last Name MI Birth Date

DENTAL HISTORY

Reason for Today's Visit Date of last dental care

Your Former Dentist Date of last dental Xrays

Address

Have you had problems with any of the following? Bad Breath Grinding Teeth Sensitivity to Hot Bleeding Gums Loose Teeth or Broken Fillings Sensitivity to Sweets Clicking or Popping Jaw Periodontal Treatment Sensitivity when Biting Food Collection between Teeth Sores or Growths in your Mouth Sensitivity to Cold

How often do you floss? How often do you brush?

MEDICAL HISTORY

Physician's Name Date of Last Visit

Have you had any serious illnesses or operations? Yes No If yes, describe

Have you ever had a blood transfusion? Yes No If yes, give approximate dates

Have you ever taken any of the group of drugs collectively referred to as "fen-phen"? These include combinations of Ionimin, Adipex, Fastin (brand names of phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine). Yes No

(women) Are you pregnant? Yes No Nursing? Yes No Taking birth control pills? Yes No

Have you had or are you having any of the following? Anemia Cortisone Treatments Hepatitis Scarlet Fever Arthritis, Rheumatism Persistent Cough High Blood Pressure Shortness of Breath Artificial Heart Valves Cough up Blood HIV/AIDS Skin Rash Artificial Joints Diabetes Jaw Pain Stroke Asthma Epilepsy Kidney Disease Swelling of Feet or Ankles Back Problems Fainting Liver Disease Thyroid Problems Blood Disease Glaucoma Mitral Valve Prolapse Tobacco Habit Cancer Headaches Pacemaker Tonsillitis Chemical Dependency Heart Murmur Radiation Treatment Tuberculosis Chemotherapy Heart Problems Respiratory Disease Ulcer Circulatory Problems Hemophilia Rheumatic Fever Venereal Disease

MEDICATIONS ALLERGIES

medications you are currently taking: Pharmacy Name Phone Aspirin Barbiturates Codeine Latex Local Anesthetic Penicillin Sulfa     Other

To the best of my knowledge, the above information is complete and correct. I understand that it is my responsibility to inform my doctor if I, or my minor child, ever have a change in health.           Signature of Patient, Parent, Guardian or Personal Representative   Date       Please Print Name Clearly   Relationship to Patient

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