Asmath Noor, DDS, MDS

Norwalk Village Dental Center- 11274 E, Firestone Blvd, Norwalk, CA 90650

562-863-8600

SO WE CAN BETTER SERVE YOU

Please take a few moments to complete this survey.

Thank you for your time.

Patient Name:
E-mail
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Take a few moments to run your tongue around your teeth. Do you notice any chipped, broken or cracked teeth or fillings?
Remembering the last time you drank or ate anything cold, did any of your teeth hurt because of the cold?
Think about the last time you ate or drank anything hot. Do you remember any of your teeth hurting because of the heat?
When you chew your food, do you tend to favor one side?
When you brush your teeth, do you EVER notice that your toothbrush has a pink tint to it, or do you ever notice your gums bleeding?
The last time you looked at your teeth in the mirror, did you notice any areas where it looked like your gums were pulling loose from your teeth?
Have you noticed any change in the way your teeth fit together when you bite?
Do you feel like you have bad breath, or have you ever had a bad taste in your mouth that keeps returning?
What other concerns do you want to discuss during this visit?

Patient's Signature:

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Date:

Guardian's Signature:

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