Questionnaire

Name:
Address:
Phone Number:
Email Address:
Best time to contact you:
Do you or anyone in your home or office suffer from allergies? Yes No
Do you or anyone in your home or office suffer from frequent headaches? Yes No
Does anyone in your home or office smoke? Yes No
Do you have pets in the house? Yes No
Do you consider your utility bill to be too high? Yes No
Are some rooms in your home too hot or too cold? Yes No
Does the air in your home just seem to be stuffy? Yes No
When you come home does your house seem to be too hot or too cold? Yes No
Do you seem to have a lot of static electricity around the home or dry skin? Yes No
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