EMF Protection Questionnaire

1

First + Last Name* This field is required.

First Name

Last Name

2

Email* This field is required.

Please Enter Your Email

3

Your Mobile Phone* This field is required.

Area Code

Phone Number

4

How did you hear about us?* This field is required.

5

Is there a particular person that we may thank for referring you?

6

Are you looking to remediate a place of residence or commercial business space?

Commercial Business

Place of Residence

Both

7

Do you live in a house, condo, or apartment?

House

Condo

Apartment

8

How many walls do you share with your neighbors? (Include above and below).

9

What is the square footage of your space?

10

How many people live in your home?Please Include How Many Children There Are & Their Ages

11

How many bedrooms and bathrooms do you have?Example: 5Bd 3Bth

12

Do you have a metal roof or metal walls?

YESNO

13

Does your home have solar?

YESNO

14

Are there XL power lines in close proximity to your home or near your property?If you are not sure, you can skip this question

15

Are there any metal drums attached to the power lines in close proximity to your home or near your property?If you are not sure, you can skip this question

16

Are there any metal electrical boxes on the ground in close proximity to your home or near your property?If you are not sure, you can skip this question

17

Are there any cell towers in close proximity to your home or near your property?If you are unsure, I will send you an email immediately after you finish this questionnaire with a link to a website that will tell you based on your location. If you are currently unsure, please skip this question.

18

Please describe any unusual EMF sources related to your home that would be useful to know. (For example: do you live in a RV with several batteries within it as a power reserve?).

19

How many cellphones are used in your household?+ Add How many of your cell phones are the newer "MagSafe" iPhone 12, 13, or 14 models?

20

How many laptops are used in your household?

21

How many tablets are used in your household?

22

How many kindles are used in your household?

0/100

23

How many baby monitors are used in your household?Please add if you use any motorized white noise sound machines in your bedrooms. (They contain a spinning motor to produce the sound, not a speaker)

24

How many WiFi Routers and Extenders are used in your home?

25

How many desktop computers in your home use wireless WiFi to access the internet?

26

How many Smart TVs are used in your home?

27

How many Wireless Cable Boxes are used in your home?

28

How many Apple TV, Roku Box, or other Smart App devices that connect to WiFi are used in your home?

29

How many Wireless Gaming Stations (X-Box, PlayStation, Nintendo Switch) are used in your home?

30

How many Alexa, Echo Dot, Google Home, or Siri smart assistant devices are used in your home?

31

How many Bluetooth Speakers are used in your home?

32

How many Wireless Security/Video Monitoring system hubs are used in your home?

33

How many Wireless Printers are used in your home?

34

How many Ceiling Fans are used in your home?

35

How many Tower Fans are used in your home?

36

How many Portable A/C Units (floor, window, or wall mount) are used in your home?

37

How many Air Purifiers are used in your home?

38

How many beds are being used in your household?

39

How many beds in your home are mechanically operated?

40

Please specify if anyone in your home use any electricity-powered health equipment such as IR sauna, PEMF mat, Peloton or WiFi-connected health equipment, or CPAP machine?

41

How many people use a Smart Watch + How many people use wireless ear buds + How many people use wireless headsets/headphones (not ear buds)?

42

Does anyone operate an electric wheelchair?

YESNO

43

Please specify if you use a microwave oven and/or air frier?

YES WE USE ONE OF THESENO WE DO NOT

44

How many vehicles are used within your household?

45

How many vehicles are hybrid or electric?

46

How many vehicles use SMART wireless technology such as a GPS Navigation system or Bluetooth calling options?

47

Are you or anyone else in your household being exposed to EMFs in the workplace or school environment?

48

What is the square footage of your office?

49

How many walls do you share with the adjacent offices?(Please include spaces located above and below you.)

50

Do you have a metal roof or metal walls?

YESNO

51

Is there a cell tower located on the roof or walls of your building?

YESNO

52

Does your building have solar?

YESNO

53

Are there XL power lines, any of the metal drums attached to the power lines, metal electrical boxes on the ground, or cell towers in close proximity to your building? If s, which, and how close are they to your building?

54

Are there XL power lines in close proximity to your building?

55

Are there any metal drums attached to the power lines in close proximity to your building?

56

Are there any metal electrical boxes on the ground in close proximity to your building?

57

Are there any cell towers in close proximity to your building?

58

Please describe any unusual EMF sources related to your office that would be useful to know.

59

How many cell phones are used in your office?

60

How many laptops are used in your office?

61

How many tablets are used in your office?

62

How many kindles are used in your office?

63

Do you use a wireless headset or Bluetooth communication device while you are working? (If so then please describe.)

64

How many wireless WiFi routers and extenders, WiFi devices (printer, smart tv, alexa or google home), and Bluetooth devices (speakers) do you have in your office? Please list what they are and how many of each. (Do not include cellphones, laptops, or tablets here.)

65

How many WiFi Routers and Extenders are used in your office?

66

How many desktop computers in your office use wireless WiFi to access internet?

67

How many Smart TVs are used in your office?

68

How many Wireless Cable Boxes are used in your office?

69

How many Apple TV, Roku Box, or other Smart App devices that connect to WiFi are used in your office?

70

How many Alexa, Echo Dot, Google Home, or Siri smart assistant devices are used in your office?

71

How many Bluetooth Speakers are used in your office?

72

How many Wireless Security System Hubs are used in your office?

73

How many Wireless Printers are used in your office?

74

How many Ceiling Fans are used in your office?

75

How many Tower Fans are used in your office?

76

How many Portable A/C Units (floor, window, or wall mount) are used in your office?

77

How many Air Purifiers are used in your office?

78

Does your office have a wireless security/video monitoring system?

79

How many fans, ceiling fans, or portable air-conditioning units do you use in your office?

80

Do you use a company vehicle for work? Please indicate if it is an electric or hybrid vehicle.

81

Does your company vehicle use SMART wireless technology such as a GPS Navigation system or Bluetooth calling options?

82

How many people work in your office?

83

How much are you currently willing to invest on your EMF remediation health?

$100 - $500

$500 - $1,000

$1,000 - $3,000

Whatever it takes

84

After you schedule your consultation to go over your results, please go to the next slide and press SUBMIT or we will not receive any of your information! The $97 fee that you pay to submit this form will be credited towards EMF Remediation Product.* This field is required.