\u05e9\u05dd:___________________________________________________: Name<\/p>\n
\u05de\u05d9\u05e7\u05d5\u05d3:________:Zip\u00a0\u00a0\u05db\u05ea\u05d5\u05d1\u05ea_______________________________: Address<\/p>\n
\u05de\u05e1\u05e4\u05e8\u05d9 \u05d8\u05dc\u05e4\u05d5\u05df:…………………………………………………….. <\/strong>:Telephone Numbers<\/strong><\/p>\n \u05e2\u05d1\u05d5\u05d3\u05d4:________________:Work \u05d1\u05d9\u05ea:__________________________ Home<\/p>\n ____________________________:Email<\/p>\n \u05e4\u05dc\u05d0\u05e4\u05d5\u05df:__________________________________________________Mobile<\/p>\n \u05ea\u05d0\u05e8\u05d9\u05da \u05dc\u05d9\u05d3\u05d4:___________________________________________Date of Birth\u00a0 \u05de\u05e7\u05e6\u05d5\u05e2:_______________________________________________:Occupation<\/p>\n \u05d4\u05d5\u05e4\u05e0\u05d4 \u05e2"\u05d9:____________________________________________:Referred by<\/p>\n \u05d0\u05e0\u05d0 \u05de\u05dc\u05d0 \u05d0\u05ea \u05d4\u05e9\u05d0\u05dc\u05d5\u05df \u05d4\u05d1\u05d0: <\/strong>Please tell us about any of the following<\/strong><\/p>\n \u05d1\u05e2\u05d9\u05d5\u05ea \u05d1\u05e8\u05d9\u05d0\u05d5\u05ea\u05d9\u05d5\u05ea \u05db\u05dc\u05dc\u05d9\u05d5\u05ea:_________________________:General health problems<\/p>\n \u05e8\u05d2\u05d9\u05e9\u05d5\u05ea \u05dc\u05ea\u05e8\u05d5\u05e4\u05d5\u05ea:______________________________________:Drug allergies<\/p>\n \u05e8\u05d2\u05d9\u05e9\u05d5\u05ea \u05dc\u05d4\u05e8\u05d3\u05de\u05d4 \u05de\u05e7\u05d5\u05de\u05d9\u05ea:_______________________:Reaction to anesthesia<\/p>\n \u05d0\u05e0\u05d9 \u05dc\u05d5\u05e7\u05d7\/\u05ea \u05d0\u05ea \u05d4\u05ea\u05e8\u05d5\u05e4\u05d5\u05ea \u05d4\u05d0\u05dc\u05d5 \u05d1\u05d0\u05d5\u05e4\u05df \u05e1\u05d3\u05d9\u05e8: \u00a0 :I take these medications regularly<\/p>\n ____________________________________________________<\/p>\n \u05e0\u05d9\u05ea\u05d5\u05d7 \u05d1\u05e2\u05d1\u05e8:_________________________________________:Prior surgery<\/p>\n \u05de\u05d7\u05dc\u05ea \u05dc\u05d1: __________________________________________:Heart ailment<\/p>\n \u05e1\u05db\u05e8\u05ea:________________________________________________:Duabetes<\/p>\n \u05e7\u05d3\u05d7\u05ea \u05e9\u05d9\u05d2\u05e8\u05d5\u05df:_____________________________________:Rheumatic fever<\/p>\n \u05de\u05d7\u05dc\u05ea \u05d4\u05e0\u05e4\u05d9\u05dc\u05d4:___________________________________________:Epilepsy<\/p>\n \u05e6\u05d4\u05d1\u05ea:___________________________________________(Heppatitis(A\/B\/C<\/p>\n \u05dc\u05d7\u05e5 \u05d3\u05dd \u05d2\u05d1\u05d5\u05d4:___________________________________:High blood pressure<\/p>\n \u05de\u05d7\u05dc\u05d5\u05ea \u05e0\u05e9\u05d9\u05de\u05d4:___________________________________:Respiratory disease<\/p>\n \u05d0\u05d9\u05d9\u05d3\u05e1:______________________________________________:HIV positive<\/p>\n \u05d1\u05e2\u05d9\u05d5\u05ea \u05d3\u05d9\u05de\u05d5\u05dd:____________________________________:Prolonged Bleeding<\/p>\n \u05d1\u05e2\u05d9\u05d5\u05ea \u05d1\u05e7\u05e8\u05d9\u05e9\u05ea \u05d3\u05dd:_______________________________:Healing complications<\/p>\n \u05d4\u05d0\u05dd \u05d0\u05ea \u05d1\u05d4\u05e8\u05d9\u05d5\u05df?\u05d1\u05d0\u05d9\u05d6\u05d4 \u05e9\u05d1\u05d5\u05e2?______________?Are you pregnant? What week<\/p>\n \u05d4\u05d0\u05dd \u05e9\u05d9\u05e0\u05da \u05e8\u05d2\u05d9\u05e9\u05d5\u05ea \u05dc:………………………………<\/strong>?Are your teeth sensitive to<\/strong><\/p>\n \u05dc\u05d7\u05e5 \u05d1\u05dc\u05e2\u05d9\u05e1\u05d4______Biting pressure , \u05de\u05ea\u05d5\u05e7______Sweets , \u00a0 \u00a0 \u00a0\u05e7\u05d5\u05e8______Cold \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0\u05d7\u05dd______Heat.<\/p>\n \u05d0\u05d5\u05db\u05dc \u05e0\u05db\u05e0\u05e1 \u05d1\u05d9\u05df \u05e9\u05d9\u05e0\u05d9\u05da?________________?Does food catch between your teeth<\/p>\n \u05d4\u05d7\u05e0\u05d9\u05db\u05d9\u05d9\u05dd \u05de\u05d3\u05de\u05de\u05d5\u05ea \u05d1\u05d6\u05de\u05df \u05d4\u05e6\u05d7\u05e6\u05d5\u05d7?_______________?Gums bleed when brushing<\/p>\n \u05e0\u05e4\u05d9\u05d7\u05d5\u05ea \u05d7\u05e0\u05d9\u05db\u05d9\u05d9\u05dd \u05d1\u05d0\u05d6\u05d5\u05e8 \u05e9\u05df \u05db\u05dc \u05e9\u05d4\u05d9\u05d0?_______________?Gum swelling around teeth<\/p>\n \u05e8\u05d9\u05d7 \u05e8\u05e2 \u05d0\u05d5 \u05d8\u05e2\u05dd \u05e8\u05e2 \u05de\u05d4\u05e4\u05d4?______________?Unpleasant taste or odor in mouth<\/p>\n \u05d4\u05d0\u05dd \u05d0\u05ea\u05d4 \u05de\u05e8\u05d5\u05e6\u05d4 \u05de\u05de\u05e8\u05d0\u05d4 \u05e9\u05d9\u05e0\u05d9\u05da?_____________________________________<\/p>\n ___________________?Are you satisfied with teeth and their appearance<\/p>\n \u05d4\u05d0\u05dd \u05d4\u05de\u05d7\u05e9\u05d1\u05d4 \u05e2\u05dc \u05de\u05d9\u05de\u05d5\u05df \u05d4\u05d7\u05d6\u05e8\u05ea \u05e4\u05d9\u05da \u05dc\u05de\u05e6\u05d1 \u05d1\u05e8\u05d9\u05d0\u05d5\u05ea\u05d9 \u05de\u05e2\u05d5\u05dc\u05d4 \u05de\u05d8\u05e8\u05d9\u05d3\u05d4 \u05d0\u05d5\u05ea\u05da?___________________<\/p>\n Are you very concerned about the finances needed to return your mouth to excellent dental health?______________________________________<\/p>\n \u05d4\u05d0\u05dd \u05d9\u05e9 \u05dc\u05da \u05e4\u05d7\u05d3\u05d9\u05dd \u05db\u05dc \u05e9\u05d4\u05dd \u05de\u05e8\u05d5\u05e4\u05d0 \u05e9\u05d9\u05e0\u05d9\u05d9\u05dd?______?Do you have any dental fears<\/p>\n \u05de\u05ea\u05d9 \u05d4\u05d9\u05d4 \u05d1\u05d9\u05e7\u05d5\u05e8\u05da \u05d4\u05d0\u05d7\u05e8\u05d5\u05df \u05d0\u05e6\u05dc \u05e8\u05d5\u05e4\u05d0 \u05e9\u05d9\u05e0\u05d9\u05d9\u05dd?______________________________<\/p>\n ____________ ?When was your last dental appointment<\/p>\n \u05dc\u05de\u05d4 \u05e2\u05d6\u05d1\u05ea \u05d0\u05ea \u05e8\u05d5\u05e4\u05d0 \u05d4\u05e9\u05d9\u05e0\u05d9\u05d9\u05dd \u05d4\u05e7\u05d5\u05d3\u05dd \u05e9\u05dc\u05da?_______________________________<\/p>\n Why did you leave your last dentist?_____________________________<\/p>\n","protected":false},"excerpt":{"rendered":" \u05d8\u05d5\u05e4\u05e1 \u05d1\u05e8\u05d9\u05d0\u05d5\u05ea \u05e9\u05dd:___________________________________________________: Name \u05de\u05d9\u05e7\u05d5\u05d3:________:Zip\u00a0\u00a0\u05db\u05ea\u05d5\u05d1\u05ea_______________________________: Address \u05de\u05e1\u05e4\u05e8\u05d9 \u05d8\u05dc\u05e4\u05d5\u05df:…………………………………………………….. :Telephone Numbers \u05e2\u05d1\u05d5\u05d3\u05d4:________________:Work \u05d1\u05d9\u05ea:__________________________ Home ____________________________:Email \u05e4\u05dc\u05d0\u05e4\u05d5\u05df:__________________________________________________Mobile \u05ea\u05d0\u05e8\u05d9\u05da \u05dc\u05d9\u05d3\u05d4:___________________________________________Date of Birth\u00a0 \u05de\u05e7\u05e6\u05d5\u05e2:_______________________________________________:Occupation \u05d4\u05d5\u05e4\u05e0\u05d4 \u05e2"\u05d9:____________________________________________:Referred by \u05d0\u05e0\u05d0 \u05de\u05dc\u05d0 \u05d0\u05ea 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