Client Data Form

Current Debt Repayments

Living Expenses*

	Amount $	Payment Frequency
General
Rent
Food
Power/Phone/Gas/Internet/Water
Vehicle (Petrol/WOF/Maintenance)
Rates
Insurance (House/Contents/Car)
Personal Expenses
Education Fees

Personal Health Cont:

{name1:first}

Have you experienced symptoms, been diagnosed, treated, or investigated for any of the following?:
Select all that apply*

Mental health conditionAny form of cancerA cardiovascular conditionA neurological conditionAny form of diabetes or pre-diabetesHIV/Aids, liver or kidney failure and/or disease, or any organ donation or transplantLung disease, COPD or emphysemaAny other medical condition or injury that you have seen, or been advised to see, a medical professional forNo past or current medical conditions or injuries
Health Condition*
Please Provide Details About Your Health Condition/s:

Personal Health Cont:

{name2:first}

Have you experienced symptoms, been diagnosed, treated, or investigated for any of the following?:
Select all that apply*

Mental health conditionAny form of cancerA cardiovascular conditionA neurological conditionAny form of diabetes or pre-diabetesHIV/Aids, liver or kidney failure and/or disease, or any organ donation or transplantLung disease, COPD or emphysemaAny other medical condition or injury that you have seen, or been advised to see, a medical professional forNo past or current medical conditions or injuries
Please Provide Details About Your Health Condition/s:
Health Condition*

Estate Planning
{name1}
Do you have a will?*

YesYes, but needs updatingNo
Do you have an Enduring Power of Attorney for Personal?*

YesYes, but needs updatingNo
Do you have an Enduring Power of Attorney for Property?*

YesYes, but needs updatingNo

Estate Planning Cont
{name2}
Do you have a will?*

YesYes, but needs updatingNo
Do you have an Enduring Power of Attorney for Personal?*

YesYes, but needs updatingNo
Do you have an Enduring Power of Attorney for Property?*

YesYes, but needs updatingNo

Personal Details: