1. Do any household members smoke? Yes No

2. Are there pets in the home? Yes No

3. Are there unusual and noticeable odors? Yes No

4. Do you have an attached or free standing garage? Yes No

5. Is your home under 10 years old? Yes No

6. Has your home been tested for radon? Yes No

7. Is there evidence of moisture problems on the foundation? Yes No

8. Do you use a humidifier or dehumidifier? Yes No

9. Is there evidence of asbestos? Yes No

10. Do you have a fireplace? Yes No

11. Regarding portable air purifiers and active air cleaning systems in your home:

    A. Do you keep a portable air purifier in the bedroom? Yes No

    B. If so, is your air purifier equipped with "hepa" filtration? Yes No

    C. Is your air purifier a durable Class II medical device unit? Yes No

    D. In general, do you and your family members sleep
        thoroughly and well? Yes No

    E. Do any of your family members suffer from allergies or asthma? Yes No

    F. Does your indoor air have a source control system?
       (duct control system) Yes No

    G. Does your home have any ventilation issues? Yes No

    H. Are there any special times of year you hire an air
        cleaning service? Yes No

12. Are there any unvented gas appliances
       (for example: stove, space heater, fireplace)? Yes No

13. Do you use a high efficiency filter for your home?s forced air heating
      and/or cooling system? Yes No

14. Do you use a high-efficiency filter for your room air conditioner(s)? Yes No

15. Is the furnace in good working order and is it cleaned and inspected yearly
      by a licensed heating contractor? Yes No

16. Is dust on the furniture noticeable? Yes No

17. Do you vacuum regularly with a high-efficiency
      filter vacuum cleaner? Yes No

18. Do you have wall-to-wall carpeting? Yes No

19. Are any of the following hobbies conducted indoors: woodworking,
      jewelry making, pottery or model building? Yes No

20. Do you use professional lawn care fertilization services or
      commercial pesticides? Yes No

21. Is there any evidence of rodents, cockroaches, ants and/or insects? Yes No

22. Have you installed a carbon monoxide detector? Yes No

Please submit this form to the Indoor Health Care Network, receive a response from Heather?s Healthy Home Tips.

What is your name?

E-mail address?

Zip Code

Would you like to receive email updates from us in the future? Yes No

Thanks for participating,

Indoor Health Care Associates