Indoor Air Quality Survey

Contact Information

*First Name:

*Last Name:

*Address:

*City:

*State/Province:

*Postal Code:

*Phone Number:

*Email:

Part 1: The People In The House

Who lives in the house?

Seniors?:

Parents?:

Kids?:

Do any occupants have existing conditions?

Allergies or Asthma?

Compromised Immunities?

Other Severe Sensitivity Issues?

If any existing conditions, please explain:

What issues are the occupants experiencing?

Respiratory irritation or infection?

Eye, nose, or throat irritation?

Headaches or dizziness?

Fatigue?

Skin rash or hives?

Nausea or vomiting?

How long has the issue been going on?:

Is there a time of day that symptoms are worse?:

Is there a room in the house that feels worse than others?:

Part 2: The House Itself

How old is the house?:

How old is the HVAC equipment?:

Is there a basement or a crawlspace?:

Do you have any gas appliances?

Stove/Oven?

Washer/Dryer?

Water Heater?

Fireplace?

What is around or near the house?

Freeways?

Industrial plants or factories?

Railroads?

Farms / Ranches?

Landfill or waste sites?

Do you experience any of the following in your house?

Static electricity?

Humid or clammy rooms?

Super dry rooms or cracked wood?

Constant dust on everything?

Draft coming your fireplace?

Have you made any major changes in your house recently?

Installed new flooring?

Installed new doors or windows?

Completed any renovation?

Bought new furniture?

Brought home a new pet?

Do you have any of the following?

Cleaning Chemicals?

Paints?

Pesticides?

Fertilizers or garden chemicals?

Gasoline for equipment?

And if so, where do you store them?:

Any Additional Notes::

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