Environmental Consultation

Pre-screen Questionnaire

Welcome! Thank you for your interest in a unique personalized consultation session. So that we may be better prepared for your comprehensive consultation, please fill out this questionnaire. Once submitted, you’ll be taken to the scheduling calendar to reserve your desired time. We will be in touch, usually within 2 business days, after we receive your questionnaire with any additional information needed for our session.

1. Please complete this basic info about yourself:

First Name

Last Name

Select an Address

Phone

Gender

Age

Referred By

2a. Are you or family members (including pets) experiencing allergy related symptoms at home?

2b. Please list any other health concerns that are part of your health picture?

2c. Are you presently under the care of a medical professional for these issues?

3. What are your main concerns about your living space? Please list any specific areas or environmental factors that you would like to address. Are there any concerns about the work environment? Where do you and other family members work? Office, factory, etc?

4. What steps have you already taken or done for your main concerns? Did they help? What were the outcomes?

5. Does anyone in the house smoke cigarettes? Exercise? Eat well? Sleep well?

6. How ready and willing are you to make changes to your interior space potentially including buying habits, in order to create a healthy home, on behalf of your health?

Minimal

Moderate

Completely

7. Are you willing to get inspections, assessments or testing done if necessary?

8. Please list any inspections, assessments or testing already completed and findings.

9. Which areas of your life are negatively impacted by your current health concerns and living situation?

Career

Family

Relationships

Social life

Recreational activities

Finances