Home Intake Survey Name * First Name Last Name Email * Address Address 1 Address 2 City State/Province Zip/Postal Code Country Home type Apartment Single family home Multi-family home Condo Describe your work environment. List all residents names and ages Are you concerned about any unusual smells? Please describe what, where and when. * Age of home * Square footage of home * Is the garage attached to living space? (Yes/No) Yes No Do you have a basement? Yes No Is it finished? Option 1 Option 2 Is your basement dry or damp? Dry Damp Have you had any flooding or water damage? * If yes, where and when? Do you have pets? Yes No If yes, how many, what type and how long? * List any renovations that've been done in the last 5 years * Do you have a cedar closet or chest? Yes No How is your home heated? (Gas, Electric, Propane, Wood, etc.) If gas, what fuel is used? * If you have an air filter, what type? (HEPA, Carbon, Fiberglass, etc. or N/A) * If you have a water filter system, what type? * Do you filter shower water? Yes No List any new furniture you've acquired in the last few years Have you ever been flooded? If so, how bad? * What type of insulation is in your walls and attic? If you use pesticides, when and where do you use them? * Do you use herbicides on your lawn? If you use mothballs, where do you use them? If you've treated your house for fleas, when and where? Have you had the air ducts/furnace cleaned? When? How often? By whom? If you have a humidifier on the furnace, what's the brand? Do you have a separate air cleaner? Where? What type? Are wood burning stoves/fireplaces WETT certified installed/inspected? * How many exhaust fans do you have (ie. bathroom fan)? How many fresh air supplies do you have? * Do you have a gas or propane: Stove, Dryer, Water heater, Other? * What type of drinking water do you use? City supply Well water Where and what type of carpet or vinyl flooring have you installed within the last two years? * List hobbies worked on in the home by any family members What type of vacuum is used? Central Vacuum? HEPA vacuum? Regular vacuum? * What material is your bedroom floor? Carpet Wood Both Do you have an inner spring mattress? How old is the mattress? How old are your pillows? What material is your bedding? Have you had any water leaks in the house (plumbing, sewer, roof, basement)? When? Where? Where do you and other family members work? (office, factory, school, etc.) Are you/they bothered by anything in the work environment? What? What is your gut feel about the factor(s) that cause your symptom(s)? Other family members? What type of area do you live in? City Industrial Suburban Country Thank you!