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 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 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 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 Do you have any engineering controls in place? (choose all that apply) Sump Pump Dehumidifier Ventilator French Drain None 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 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
