Health questionnaire

Fill in your health history for your appointment with Dr Meizi Eliezer at PerioHome in Herzliya. Review your answers, sign and create a PDF on your device.

Your privacy

There is no analytics or answer storage on this form. Answers stay in this open page until you download or choose to share the PDF. Refreshing, closing or leaving the page clears the form. The website does not receive your completed questionnaire or confirm delivery to the clinic. Downloaded files and copies shared through other apps remain outside this page; please check the recipient before sharing.

Please inform your dentist of any changes in your medical status. If you are unsure about an answer or declaration, discuss it with the clinic before signing. A drawn or typed signature is included in the PDF; it is not identity verification or a certified digital signature.