Financial Health

Patient Information

Name and Last Name

Age

Phone Number

Zip Code

State

Email

Employment Status

Time in current job (years)

Quadrant 1: Assets and Liabilities

Assets

Real Estate ($)

Cars ($)

Savings ($)

Investments ($)

401k ($)

IRA/Roth IRA ($)

Total Assets: $0

Liabilities

Personal loans ($)

Mortgages ($)

Car loans ($)

Student loans ($)

Credit cards ($)

Health debts ($)

Total Liabilities: $0

Quadrant 2: Ins & Outs

Income

Employment ($)

Dividends ($)

Tips ($)

Others ($)

Total Income: $0

Expenses

Food & drinks ($)

Loan payments ($)

Credit card payments ($)

Car payments ($)

Health insurance ($)

Life insurance ($)

Car insurance ($)

Rent or housing lease ($)

Utilities ($)

Gasoline ($)

Tax ($)

Savings ($)

401K ($)

Recreation ($)

Total Expenses: $0

Mister G