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General Home Information
Type of Home:
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Size of Home:
Years at this location:
# of Residents in Home:
Years with Chronic Illness:
How many other residents have illnesses:
Home Exterior & Landscape
Home built on high point of lot
Water Collects in yard
Wall shows water damage
Water Flows toward home
Roof and Attic
Roof Leaks
Gutters Leak
Bird Damages
Wet Insulation
Blown-In Type Insulation
Rodent Damages
Home Interior
Interior Flooding
Visible Water Stains on Ceiling
Visible Water Stains on Walls
Carpets have been wet
Buckled Hardwood Flooring
Leaking Water Pipes
Leaking Sewer Pipes
Insect Damages
Rodent Damages
Pet Damages
Basement/Crawlspace Water Problems
Foul / Moldy Odors
Stains on Ceiling
Carpets have been wet
Exposed Dirt Floor
Flooding or Mold
Leaking sewer pipes
Leaking Water Pipes
Leaking A.C. Drains
HVAC System and Air Filtration
HVAC System in Attic
HVAC System in Basement
Ductwork Cleaned in the last 6 months
HVAC filters replaced in the last 30 days
HEPA System Installed
HEPA Maintained in the last 6 months
Other Air Filtration Systems Installed
Let's Take a Look at your Health
General Health Information
Unhealthly Symptoms
Allergies
Asthma
Bronchitis
Eye Infections
Ear Infections
Eczema
Sinus Congestion
Athletes Foot
Headaches
Sleep Apnea
Respiratory Inflammation
Chronic Fatigue
Life Threatening Symptoms
Fibromayalgia
chemical Sensitivities
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SIDS
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