Your Homes Health Questionnaire Company First Name * Email Address * Last Name * Mobile Number Does anyone in your home suffer from Allergies or Ashthma * Yes No On a Scale of 1-10 with 10 being the worst, How would you Rate your families respiratory issues. 1 On a scale from 1 – 10, how bad are they? During the winter, does anyone suffer from dry itchy skin, static electricity, bloody nose, or wood floors and furniture separating? * Yes No Are you concerned with the spreading of colds and flus throughout your home? * Yes No On a Scale for 1-10 with 10 being most concerned, How concerned are you. * 1 On a scale from 1 – 10, how bad are they? Do you notice odors from pets, cooking, laundry, or cleaning chemicals? * Yes No On a scale of 1-10, with 10 being highest, how strong are these odors * 1 On a scale from 1 – 10, how bad are they? Have you noticed stale air, fatigue or lack of energy? * Yes No On a scale of 1-10 how stale is the air or how much fatigue? * 1 On a scale from 1 – 10, how bad are they? Do you have excessive moisture and high humidity in your home, or do you notice a musty smell? * Yes No On a Scale of 1-10 with 10 bing highest, How high is the humidity in your home? * 1 On a scale from 1 – 10, how bad are they? Does anyone in the home use oxygen or has severe respiratory issues? * Yes No Health Air Calculator Your Home Score What does it mean 0-7 > No Actions Necessary. 8-23 > Actions Recommended (Mild Concerns) 24-47 > Actions Recommended (Moderate Concerns) 48-70 > Actions Necessary (Severe Concerns)
