Questionnaire for Healthy Home/IAQ Assessments Please enable JavaScript in your browser to complete this form.Your name *Address *Email address *Phone no *Zip code *How did you hear about us *Building Biology Institute websiteInternet searchMy doctorWord of mouthOtherService requested *A. Environmental/IAQ inspection ($350)>> Optional: Add a written report to A ($150)B. Water intrusion inspection with thermal imaging ($400)C. Mold spores in air with 3 samples ($390)>> Optional: Add 1 more air sample to C ($60)>> Optional: Add 1 surface sample using Tape/Swab to C ($60)>> Optional: Add 2 surface samples using Tape/Swab to C ($120)D. Dust/particle analysis with 1 sample ($345)>> Optional: Add 1 more sample area to D ($65)E. VOCs with 1 sample ($650)>> Optional: Add 1 more sample area to E ($320)F. Tobacco smoke with 1 sample ($650)>> Optional: Add 1 more sample area to F ($325)G. Formaldehyde with 1 sample ($425)>> Optional: Add 1 more sample area to G ($150)Combinations (in the same visit): Check below based on what you have chosen aboveCombine (A + B) or (A + C) or (B + C): $100 discountCombine (A + B + C): $200 discountCombine (A + D): $100 discountCombine (C + D): $245 discountCombine (E + F): $400 discountIf you have a coupon code, please enter belowDescribe any other combinations or services you would like to have a quote forHouse type where inspection/sampling is needed *Single familyTownhomeApartment/CondoOwnership *Currently ownCurrently rentPlanning to purchase/move intoIs there a current or pending litigation or dispute on the house involving mold or any other issues? *Yes (please explain below)NoExplain if you answered "Yes" aboveTotal house size in square feet including basement *Year built *Location *CitySuburbanCountryIndustrialDescribe any pollution source within 1 mile (landfill, airport, etc.) Foundation Type *Finished basementUnfinished basementCrawlspace - usually dampCrawlspace - usually drySlabNumber of bedrooms *Number of floors (without basement) *Floor type *Hardwood floorsCarpeted floorsBothNumber of occupants *Number of children under 10 *Number of people who smoke *Number of pets *Cooking type *Gas cookingElectric cookingInductive (magnetic) cookingWoodstove cookingDescribe any health issues of the occupants. Breakdown by each occupant. (Write "N/A" if no health issues)House mechanicals *HVAC systemMetal ductsBaseboard heatingSplit system for heating/coolingWindow ACSolar panelGas fireplaceWood burning fireplaceRadiant floor heatingHRV/ERV ventilation systemWhen was the ducts cleaned last time? (Write "N/A" if not applicable) *When was the furnace cleaned last time? (Write "N/A" if not applicable) *When you had last carpet changes done? (Write "N/A" if not applicable) *How often do you vacuum the house? (Write "NA" if not applicable) *Does your vacuum have a HEPA filter?YesNoI do not use vacuum cleanersDescribe any water leak or flood incident that occurred in the past and whenDo you currently see any visible mold in the house? *YesNoDescribe any past known mold incidenceDescribe any major renovations done in the last 5 yearsChemical usageWe use chemical fertilizers in lawn and gardenWe use pesticide, etc. in my lawn and gardenWe use typical chemical cleaning suppliesWe only use non-toxic, natural cleaning suppliesAcknowledgement: Depending on which service you request, we may thoroughly inspect various parts of the house, including bed rooms, cabinets, under sink, refrigerators, and more. We also take many pictures. The homeowner or an adult must be present during the entire home visit, which may take 2-3 hours or more depending on the service requested. *I acknowledge and give permissionI do not agreeSubmit
