Welcome to Jenkins & Morrow

Name:

Age:

Referring Dentist:

Primary Care Physician:

Medical Conditions:

Cardiac Disease
Lung Disease/Asthma
Liver Disease
Kidney Disease
Diabetes
Cancer
Bleeding Problems

Please explain condition(s):

Medications:

Allergies:

Hospitalization:

Previous Surgeries:

Under Care of a Physician?

YES	NO	If yes, please explain:

Review of Systems

Asthma Hepatitis TB Blood Disease Rheumatic Fever Heart Murmur Heart Attack Chest Pain	Glaucoma Anemia Lung Disease Seizures Stomach Ulcers Stroke Heart Disease Change in Vision	Cough Shortness of Breath Sinusitis Cancer Arthritis Kidney Disease High Blood Pressure Immune Deficiency

Please explain all selected:

Social History

Married Single Divorced	Alcohol Tobacco Packs Per Day:	Pregnant Birth Control

Occupation:

Family History

Problems with General Anesthesia
Bleeding Problems
Heart Problems
Diabetes
Cancer

Please explain condition(s):


	Copyright © 2007 Jenkins & Morrow \| All rights reserved. \| 216 Fountain Ct., Suite 110 \| Lexington, KY 40509 Phone: 859-264-1898 \| Fax: 859-685-0118 W. Scott Jenkins, DMD, MD \| Nick S. Morrow, DMD