Code No. 507.4E
PARTS OF BODY INJURED
HEAD/NECK UPPER EXTREMITIES LOWER EXTREMITIES TRUNK
__Skull __Shoulders R/L __Hips R/L __Upper Back
__Face __Upper Arms R/L __Thighs R/L __Lower Back
__Neck __Elbow R/L __Knee R/L __Collarbone
__Ear(s) R/L __Forearm(s) R/L __Lower Leg(s) R/L __Chest
__Eye(s) R/L __Wrist(s) R/L __Ankle(s) R/L __Lung(s)
__Nose __Hand(s) R/L __Foot R/L __Ribs
__Teeth __Finger(s) R/L __Toe(s) __Pelvis
__Mouth __Internal
SPECIFIC TYPE OF INJURY
__Amputation __Concussion __Inflammation __Puncture
__Asphyxiation __Cut/Laceration/Abrasion __Ligaments/Cartilage __Shock(Elec)
__Bite __Dislocation __Overheated __Sprain/Strain
__Bruise __Fracture __Paralysis __Sting
__Burn __Frostbite __Poisoning __Teeth Injury
__Chest Pain __Hearing Loss (solid, liquid, gas, vapor) __Vision Loss
__Other (Specify)
MARK INJURED AREAS OF BODY