HOME AIR QUALITY CHECK
See if your home qualifies for a FREE Fresh Air Machine* ($170 Value) *Office guidelines apply
How would you rate the air quality in your house?
*
1
2
3
4
5
Does anyone in your household suffer from allergies, asthma, or breathing issues?
*
Yes
No
Not Sure
Other
Do your kids or family members seem to get sick often?
*
Frequently
Sometimes
Rarely
Do you have pets inside your home?
*
Dog(s)
Cat(s)
Other pets
No pets
Do you ever notice lingering odors in your home?
*
Pet Odors
Cooking Odors
Musty Smell
Smoke Smell
Other
How quickly does dust build up in your home?
*
Very Quickly
Within a few days
About a week
Hardly noticeable
Other
How old is your home?
*
Under 10 years
10-20 years
20-30 years
30+ Years
Does your home ever smell stale after being closed up?
*
Yes, Often
Occasionally
No
Are you currently doing anything for Air Quality in your house?
*
Yes, Often
No
Other
Are you...
*
Married
Living Together/ Cohabitate
Single
Widow
Room-mates
What age group are you in...
*
Under 25
26-34
35-44
45-54
56-64
65-74
75+
First & Last Name
*
Partner First & Last Name
*
If single (put NA)
Phone Number
*
Best time to call or text?
*
Morning
Afternoon
Evening
Other
What is your occupation?
*
What is your partners' occupation?
*
Type NA if doesn't apply
Do you...
*
Own
Rent
Live w/ Friends/ Family
Describe any issues or observations about the air quality (optional)
Submit
Should be Empty: