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Asterisks * indicates required fields.
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| 1. Have you had any water leaks (including toilet, tub overflows, water heaters, and air conditioners) that caused the surrounding areas to get wet? |
Yes |
| 2. Have you ever had roof leaks that went on for a period of time exceeding 24 hours? |
Yes |
| 3. Do you have carpet in your bathroom or wood floors in your kitchen? |
Yes |
| 4. Do you have carpet in your home older than 3 years? |
Yes |
| 5. Do you change your Air Conditioning filter less often than every 30 days? |
Yes |
| 6. Is your Air Conditioner filter the old see-through (non-HEPA compliant) style we have used for years? |
Yes |
| 7. Have you have your Air Conditioner and ducts cleaned and checked in the last 6 months? |
Yes |
| 8. Do you have excessive condensation on your windows or window sills? |
Yes |
| 9. Can you see signs of mold growth in your home? |
Yes |
| 10. Have you observed musky odors when you come home after work or after it rains? |
Yes |
| 11. Do you have children under the age of 6 or adults over the age of 60 in the household? |
Yes |
| 12. Are you or anyone in your family having difficulty breathing, asthma, unexplained nose bleeds, sinus problems, headaches or fever? |
Yes |
| 13. Do you have pets in the home? |
Yes |
| *Your Name |
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| *E-Mail Address |
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| *Phone |
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| Street Address |
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| Comments |
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