Indoor Air Quality Questionnaire Indoor Air Quality Questionnaire Name * Email * Phone * Street Address * City * we do not share or sell your personal information, all information is kept confidential. Concerns * Where are you experiencing the issue? (choose all that apply) * Basement Crawl space First floor Second floor Attic Unknown/Other NA When do you encounter odors in the property? * All the time Sometimes Seasonal Please describe the odors that you smell (choose all that apply) * Musty Chemical Urine Locker room Unknown NA What kind of conditioning (heating/cooling) do you have? (choose all that apply) * Forced air Baseboard/radiator Wall mounted AC Central AC Heat only AC only NA What is the age of the structure? * What is the age of the structure?Newer construction2010-19901990-19401940-1900Pre-1900 Have any repairs or renovations been completed on the structure? (choose all that apply) * Structure expansion Full renovation Kitchen renovation Bathroom renovation Basement finish New roof and/or window Exterior (patio/pool) None/Unsure NA Do you have any engineering controls in place? (choose all that apply) * Sump Pump Dehumidifier Ventilator French Drain None NA What health issues are the occupants experiencing? (choose all that apply) * Coughing and/or sneezing Sore throat Congestion Bloody nose Stomach/intestinal issues Weight gain or loss Hair loss Skin issues Headaches Brain fog Memory issues Balance difficulty Joint pain None NA Have health issues been diagnosed by a doctor? * Yes No Please provide any further information or details you would like to share. Please attach any previous lab results, Investigative reports, or photos. Photos / Video Drop a file here or click to upload Choose File Maximum file size: 52.43MB Reports (pdf, doc, docx) Drop a file here or click to upload Choose File Maximum file size: 52.43MB Lab Results (pdf, doc, docx) Drop a file here or click to upload Choose File Maximum file size: 52.43MB Submit If you are human, leave this field blank. Δ
