Questionnaire for Comprehensive EMF Assessment Please enable JavaScript in your browser to complete this form.Your name *Home address where assessment is needed *Email *Phone no *How did you hear about us *Internet searchBuilding Biology Institute websiteMy doctorWord of mouthOtherIf you have a coupon code, please enter belowHouse type *Single familyTownhomeApartment/CondoHouse location *Subdivision complexRural/county areaWithin the cityOwnership *OwnRentHouse size in square feet (without basement) *Year builtFoundation Type *Finished basementUnfinished basementCrawlspaceSlabGarage type *Attached garageDetached garageNo garageNumber of bedrooms *Is there a separate office room? ((If you spend long hours in a home office, we recommend that you have it assessed for EMF) *YesNoNumber of floors (without basement) *Number of occupants *Number of children under 10 *Number of people who smoke *Sleep pattern *I sleep well and wake up well-restedI have difficulty sleeping at night or do not feel well-restedMy spouse sleeps well and wakes up well-restedMy spouse have difficulty sleeping at night or does not feel well-restedIs anyone in your house diagnosed as electrically hypersensitive (EHS)? *YesNoI do not know, but I feel discomfort around EMF fieldsDescribe any health issues of the occupants. Breakdown by each occupant. (Write "N/A" if no health issues)House mechanicals *City water serviceWell waterGas servicePhone line (landline)Cable TV lineHVAC systemMetal ductsBaseboard heatingSplit system for heating/coolingWindow ACSolar panelKnob and tube wiring system3-way switchesDimmer switchesElectric generatorElectric ovenInduction (magnetic) ovenBattery backup systemNotable appliances/devices *Battery backup systemsFluorescent lights (white tube lights)CFL lights (energy-saving "spiral" lights)White noise sound device (sleeping aid)Humidifier/de-humidifierFish tankFloor fansMetal bed frameWireless electronics used inside the house *Wireless routerWireless thermostatWireless baby monitorWireless keyboard/mouseWireless doorbellWireless smoke detectorCordless phoneBluetooth devicesMicrowave (if used)Smart electric meterSmart TV (Wi-Fi)Smart Oven (Wi-Fi)Smart Fridge (Wi-Fi)Smart Washer/Dryer (Wi-Fi)Other wireless devicesIs there a nearby airport or airfield? If yes, please mention its name, how far away it is from your home, and in which direction.Number breaker panels/subpanels *Number of active cell phone users *Number of active TV sets *Number of active iPads/tablets *Any other electronic devicesService type *Comprehensive EMF Assessment with verbal report ($550)Comprehensive EMF Assessment with professional report ($750)Option: 9-Point bed mapping is covered for one room (usually the master bedroom) *Bed mapping for one room (included)Add bed mapping for 1 more room (+$50)Add bed mapping for 2 more rooms (+$100)Option: Body Voltage testing is covered for one room (usually the master bedroom) *BV testing for one room (included)Add BV testing for 1 more room (+$75)Add BV testing for 2 more rooms (+$150)Option: EMF assessment is covered for up to 5 rooms/areas (usually the 3 bedrooms, kitchen, living/family room) *E-field, M-field, and RF assessment for five rooms/areas (included)Add these assessments for 1 more room (+$50)Add these assessments for 2 more rooms (+$100)Add these assessments for 3 more rooms (+$150)Option: Blower test to check service neutral (this is recommended if plumbing current is detected) *Decline ($0)Do this test if plumbing current is found (+$100) - See Acknowledgement 1 below.Acknowledgement 1: We are not certified electricians and do not open breaker panels. For us to do this test, the homeowner must open and close the breaker panel at his/her own risk. Under no circumstances, shall the we be held responsible for any injury or damage as a result of opening or closing the breaker panel or doing this inspection. *I acknowledgeSkip this serviceAcknowledgement 2: Please prepare a rough sketch of your floorplan - one for each floor. Then email it to mr@yoursafeliving.com 2 days prior to the home visit *I acknowledgeAcknowledgement 3: We may turn circuit breakers on/off many times, which is necessary for assessing EMF under various loads. If you have any device, equipment, or appliance that might potentially be damaged due to this, we are not responsible. You can unplug them during the entire assessment period or leave them plugged at your own risk. Also, the homeowner or an adult must be present during the entire home visit, which may take 2-6 hours depending on which service you request. *I acknowledge and give permissionI do not give permissionSubmit
