1. What is your monthly prescriptions cost?

$

2. How much are your monthly doctor visit copays?

$

3. How much are your monthly medical bills?

$

4. How much are your monthly dentist bills?

$

5. What is your monthly health insurance cost?

$

6. What is your monthly life insurance cost?

$

7. Do you have any other medical expenses? If yes, list the amount.

$

8. Do you have any other insurance expenses? If yes, list the amount.

$