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1. Do you have or use any of the following at/near home or work?
a. Spring water
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b. Well water
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c. Water purifier
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d. Damp cellar
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e. Wooded area
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f. Swamp
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g. Power lines
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h. Microwave transmitter
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i. Smoke stacks
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j. Dump
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k. Gas stove
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l. Gas furnace
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m. Gas hot water heater
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n. Gas dryer
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o. Wood stove
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p. Coal stove
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q. Kerosene space heater
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r. Forced hot air heat
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s. Electric blankets
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t. Feather pillows
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u. Foam rubber pillows
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v. Feather/down Comforter
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w. Coat/jacket
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x. Stuffed upholstery
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y. Animals
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z. Polyester blend in Sheets
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aa. Pillow case
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ab. Pajamas
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ac. Shirts
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ad. Skirts
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ae. Pants
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af. Exterminator
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ag. Moth balls
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ah. Mold on Shower curtain
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ai. Basement walls
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aj. First story walls
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ak. Second story walls
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al. Garage under living space
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am. Urea formaldehyde insulation
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an. Other
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2. Are you bothered by: (check appropriate selections)
a. Gasoline fumesb. Diesel exhaustc. Soapsd. Detergentse. Chlorinated waterf. Moth ballsg. Asphalt/tarh. Hair sprayi. Cosmeticsj. Perfumek. Dustl. Fabric storesm. New car smelln. Air conditionerso. Newsprintp. Tobacco smokeq. Catsr. Dogss. Moldt. Tree pollenu. Grass pollenv. Ragweed pollen
3. Please check appropriate selections about carpeting in your home.
BEDROOM
a. Noneb. Area rugsc. Wall to walld. Woole. Synthetic padf. Glued downg. How old is carpeting?
LIVING ROOM
h. Nonei. Area rugsj. Wall to wallk. Wooll. Synthetic padm. Glued downn. How old is carpeting?o. On slabp. Ever damp?q. Moldy
FAMILY ROOM
r. Nones. Area rugst. Wall to wallu. Woolv. Synthetic padw. Glued downx. How old is carpeting?y. On slabz. Ever damp?aa. Moldy
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