Mouth And Dental Chart Bodily Injury Chart (Page 2 of 2) in pdf

Mouth And Dental Chart Bodily Injury Chart Page 2

BODILY INJURY CHART

Do you have breast implants? Yes or No

Any surgical implants, prostheses, cosmetic surgeries, medical surgeries?______________________________________________

In the space provided after each question, help to explain trauma areas and use the figure’s below to specify the location:

Any tattoos or piercings? Y or N

Back injuries? Y or N

Herniated disk? Y or N

Head/neck injuries? Y or N

Pace maker? Y or N

Have you had a physical exam in the last 12 months? Yes or No

Have you had a colonoscopy in the last 12 months? Yes or No

Do you have a pacemaker?

Have you had a mammogram or thermography in the last 12 months? Yes or No

Write injury site below, associate letter with graph

A)_________________________________ F)_________________________________ K)______________________________

B) ________________________________ G)_________________________________ L)______________________________

C)_________________________________ H)_________________________________ M)______________________________

D)_________________________________ I)__________________________________ N)______________________________

E)_________________________________ J)__________________________________ O)______________________________

Mouth And Dental Chart Bodily Injury Chart Page 2