Indoor Environmental Background Info Form

First Name

Last Name

Email

Phone

Address

Address Line 1

Address Line 2

City

Country

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State/Province

Select Select AA AE Alabama Alaska American Samoa AP Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas United States Minor Outlying Islands Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

Zip Code

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Square footage of home:

How many levels does the home have?

Do not count basements, attics or crawlspaces.

Select Select 1 2 3 4 or more

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What kind of foundation does your home have?

Select Select Slab Crawlspace Basement Not sure

If there is a basement, is it conditioned (finished) or unconditioned (unfinished)?

Select Select Conditioned Unconditioned

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Where is the HVAC unit located? (It's typically found in the attic or crawl space).

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Have there been any recent water issues? (These may include issues such as roof leaks, plumbing leaks, visible puddles, and water staining.)

Select Select Yes No

If there have been water issues, do you know where the leak originated? How long has the leak persisted and what seems to be wet?

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Have you noticed any signs of mold (“mildew”) issues indoors?

Select Select Yes No

If so, where do you see it and how can you best describe it?

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Do you smell any musty odors associated with the potential water or mold issue?

Select Select Yes No

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Have you experienced allergy or sick-like symptoms within the home that you feel may be attributed to the home? (These may include coughing, sneezing, skin rashes, headaches, eye irritation, throat irritation, and tiredness)

Select Select Yes No

If yes, when?

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How many people live in the home?

How many of the inhabitants are children?

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Do you have pets indoors?

Select Select Yes No

If so, how many and what kind?

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Do you have plants indoors?

Select Select Yes No

If so, approximately how many ?

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Do you have carpeting throughout the home?

Select Select Yes No

Does anyone smoke indoors?

Select Select Yes No

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Have you recently repainted the home or performed any recent renovations?

Select Select Yes No

If so, please elaborate:

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Please list any general notes and/or concerns you have:

What do you hope to learn or accomplish from ESG’s assessment?

Signature: I certify that my answers are true and complete to the best of my knowledge.

ESG will use this information to better assist you and will be in contact with you once this information has been reviewed. Please type your name below.

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