We appreciate you choosing our Smiles on Hudson and Dr. Gold.

BEFORE your first appointment
, please take a moment to provide us information about your dental health.
When you're finished, click on the SUBMIT button at the bottom of the page.

Please choose one response from each question:

1. My mouth is Very Comfortable Moderately Comfortable Uncomfortable

2. I am satisfied with the appearance of my mouth. Yes No

If not, what are you not satisfied with?

3. Do you want to set goals for your oral health? Yes No

4. Is there anything that you would like to know about Dr. Gold?

5. How can we help you to be comfortable in our office?

6. Have you ever had any serious problems associated with dentistry?

7. Does dental treatment make you nervous?

8. Have you been treated for periodontal or gum disease?

9. What things are important to you regarding your dental health?

10. Do you have any pain in your teeth or any part of your mouth because of heat, cold, sweets, or while biting or chewing?

11. Do your gums bleed when you brush or do they feel tender, irritated, or swollen?

12. Do you have missing teeth and if so, how long have they been missing?  Would you like to have them replaced?  If not, why?

13. Does food catch between your teeth?  If so, where?

14. Do you ever experience aches or pain in the side of your face in the area of the ears or are you subject to chronic headaches?  Do you have neck or shoulder pain?

15. Have you had a lot of dental treatment in the past?  If so, has it been to replace previous dentistry or repair newly decayed areas?

Please provide any additional comments/suggestions you may have.

Name: (First/Last)


Preferred Phone:


Robert T. Gold, D.D.S. | 2018 Albany Post Road | Croton-On-Hudson, NY 10520 | (914) 271-4726
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