Please fill out this questionnaire to the best of your ability, and return it to Pinyon at least 24 hours prior to your scheduled test time.
Have you previously had environmental testing completed in your home? Yes No
If so, for what?
What were the results?
Can you provide a copy of the report to Pinyon? Yes No
Does your home have a basement? Yes No
Does your home have a crawlspace? Yes No
If so, describe:
Other than your basement, how many floors?
Year Built:
How long have you been living there?
Have you remodeled lately? Yes No
Are you planning on remodeling in the next year? Yes No
How many bedrooms?
How many bathrooms?
Do you have an indoor hot tub or sauna? Yes No
If so, where is it located?
Is your water from a well? Yes No
If no, who is your water utility company?
Are you on septic or municipal sewer? Yes No
How is the house heated?
Do you have central air? Yes No
Do you have a swamp cooler? Yes No
Do you have window air conditioners? Yes No
Do you have a gas stove/oven? Yes No
Do you have a wood burning stove? Yes No
Do you have a fireplace? Yes No
Have you noticed standing water in your home? Yes No
Do you know of water leaks in your home? Yes No
Have you noticed water staining on your floors, walls or ceiling? Yes No
Do you have a sump pump? Yes No
If so, how often does it run?
Have you noticed "musty" odors in your home? Yes No
How many people in the household smoke?
Is there anyone living there over 65? Yes No Under 2? Yes No
If so, please provide ages
Does anyone in the household have health problems (particularly related to allergies or respiratory problems)? Yes No
Has a doctor been consulted? Yes No
If so, have they offered an opinion of the cause of the problem?
How many dogs in the home?
How many cats in the home?
Other pets?
Comments: Please submit: Thank you for taking the time to complete this questionnaire. Your answers will assist in our evaluation of your home.