Mouth And Dental Chart Bodily Injury Chart printable pdf download

Mouth And Dental Chart Bodily Injury Chart

MOUTH AND DENTAL CHART

Use the chart below to mark where you have fillings, caps, crowns, inlays, composites, root canals, bridge work

etc.

Upper

teeth

Lower

teeth

DENTAL HISTORY: Circle which ones you have:

Silver filings

Gold crowns or inlays

Root canals

Braces

Composites

Stainless steel crowns or inlays Root canals with EndoCal

Bleeding gums

Extractions

Porcelain crowns or inlays

Posts

Sensitive teeth

Bridgework

Implants

Over bite

Under bite

Partial/full dentures

Veneers

Temporaries

New Cavities

Have you had your wisdom teeth removed? ________________________________________________

Dental surgery? ________________________________________________________________________

Complete Tongue Diagnosis: Mark findings on the picture

showing areas of consideration and explain below.

Findings:

Body Color (i.e. red) look at sides, the tip, back:

Coating Color (i.e. yellow, white, green):

Shape (i.e. swollen, sides indented, flat, concaved):

BODILY INJURY CHART

Texture (i.e. center crack, smooth, slimy, raw):

Mouth And Dental Chart Bodily Injury Chart