Take Our Air Health Assessment - Active Healthy Lifestyles

Full Name

Email Address

Your home/office was built in what year?*

Or how old is your home?*

How many square feet?*

Square feet not included above?

How many floors*

Split Level*

Yes
No

Basement?*

Yes
No

Damp Basement?*

Yes
No

Mold or Stale Odors?*

Yes
No

Any other odors?*

Crawl Space?*

Yes
No

# of Bathrooms

# of Bedrooms

On an average day, how many hours do you spend indoors?

Sick Building Syndrome: In order to conserve energy, we have sealed our homes and businesses. This lowers the amount of outdoor air ventilation thus indoor air pollution has increased. Stale air. Indoor air 4-5 times more polluted than outdoor air.

Number of smokers?

Pets? How many?

What kind of pets?

Do you have a central HVAC system?*

Yes

How many ceiling fans?

Number of people living in the home/office?

Check All you Have In your Home*

These chemicals give off toxins that you and your family are breathing every day.

Do you own: Wood-burning stove, fireplace, non-vented kerosene or gas space heater(s)?*

Biological contaminants include things brought in from outdoors: bacteria, mold, mildew, pollens, viruses, insect & bird droppings, motor vehicle fumes, pesticides, etc.*

Yes
No

Does anyone in the home have airborne allergies?remodeling, carpets.*

Yes
No

Recent remodeling, carpets.*

Yes
No

Does anyone suffer with respiratory problems?*

Yes
No

Family members get sick and share germs with everyone in the home/office*

Yes
No

Do you see dust floating in your home/office especially on sunny days?members get sick and share germs with everyone in the home/office*

Yes
No

Do you use chemical sprays or wipes to kill germs?*

Yes
No

Chemical sensitivity?*

Yes
No

Do you travel by air?*

Yes
No

Camper*

Yes
No

Hotel rooms*

Yes
No

Do you spend time where lots of people gather (movies, stores, schools, churches,*

Yes
No

How many loads of laundry to you to each week?

Laundry Pure is a machine that the water goes through before entering your washing machine. You can spend zero dollars $00.00 on detergents, fabric softeners, bleach. No hot water. Kills germs. Machine can pay for itself in less than one year and then doing your laundry is FREE!

Do you want more information?*

Yes
No

What does a healthy home look like for you?*

What are you doing now to improve the air quality of your home/office? Please describe:*

What issues are getting in the way?*

Schedule a FREE consultation and demonstration of air purifier products. We love to show you how our products create a healthy environment for you and others in your home or office. It costs nothing to learn about this. Time is 30 minutes plus any extra questions you may have.

EMAIL:
Diana@ActiveAirPurifiers.com.

WEBSITE: www.activeairpurifiers.com

PHONE: 614-506-6622

Breathing Clean Air: Home/Office Assessment

Air Purifier Health Assessment

Let’s Make a Healthy Home a Priority Today. Move from Apathy to Action.