Prescriptions
_____________/_________________/_________________/_______________________
Outstanding Bills
_____________/_________________/_________________/_______________________
Therapy/Counseling
_____________/_________________/_________________/_______________________
Eye Care
_____________/_________________/_________________/_______________________
Equipment
_____________/_________________/_________________/_______________________
Other
_____________/_________________/_________________/_______________________
4. DENTAL
Insurance Premiums
_____________/_________________/_________________/_______________________
Co-payments
_____________/_________________/_________________/_______________________
Orthodontist
_____________/_________________/_________________/_______________________
Outstanding Bills
_____________/_________________/_________________/_______________________
HERS
HIS
MONTHLY
ANNUAL
MONTHLY
ANNUAL
5. ENTERTAINMENT
Eating Out
_____________/_________________/_________________/_______________________
Movies
_____________/_________________/_________________/_______________________
Video Rental
_____________/_________________/_________________/_______________________
Seasonal
_____________/_________________/_________________/_______________________
Other Activities
_____________/_________________/_________________/_______________________
6. GIFTS
Birthdays
_____________/_________________/_________________/_______________________
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